LIBRARY OF CONGRESS. 



Shelf ]i£-^^ 

UNITED STATES OF AMERICA. 



L 



X 



RELATIONS 



OF 



Diseases of the Eye 



TO 



General Diseases 



/ BY 

MAX KNIES, M.D. 

Professor Extraordinary at the University of Freiburg 



FORMING A SUPPLEMENTARY VOLUME TO EVERY MANUAL 

AND TEXT-BOOK OF PRACTICAL MEDICINE 

AND OPHTHALMOLOGY 




HENRY D. NOYES, A.M., M.D. y^l^i^-CL^ 

Professor of Ophthalmology and Otology in Bellevue Hospital Medical College ; Executive Surgeon to the 

New York Eye and Ear Infirmary ; recently President of the American Ophthalmological Society ; 

recently Vice-President of the New York Academy of Medicine ; Permanent Member of the 

New York State Medical Society ; Member of the American Medical Association, etc., etc. 



NEW YORK 
WILLIAM WOOD & COMPANY 

1895 



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nKVi 




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Copyrighted, 1895, 
By WILLIAM WOOD & COMPANY 



EDITOR'S PREFACE. 



In presenting this treatise of Professor Knies in an English dress, 
the editor simply fulfils the function of giving to a book whose qual- 
itj' is to a great degree unique, a larger field of usefulness. Espe- 
cially in those parts which concern the nervous system is there much 
that is worth}' of attentive study, and which is not to be found in 
any other treatise. Throughout the book the alliances between the 
eye and the rest of the body are so admirably traced that it will be 
hard to decide, upon whom the larger debt of obligation to the pains- 
taking author will rest, whether upon the general physician or upon 
the ophthalmologist. 

The point of view is from the side of the general practitioner, 
who having in hand a particular case, say for example of tabes dor- 
salis, is put into possession of the various eye lesions liable to occur; 
whether these be present or absent he is prepared to understand the 
ocular phenomena. In fact, the book serves the valuable purpose of 
a cross index between the general field of medicine and an impor- 
tant specialty. On the other hand, the oculist finds his range of view 
enlarged and is made to realize in a more adequate degree, that local 
disease may depend upon and be the signal of a lesion of some re- 
mote organ or of a constitutional affection. He is made to appreciate 
the need of wide observation of symptoms, and is kept in touch with 
the pathology and therapeutics of medicine at large. 

The editor has added little to the author's pages and has not taken 
upon himself the work of translation. 

New York, Jan. 5, 1895. 



PREFACE TO THE GERMAN EDITION. 



Diseases of the eye often possess important significance in rela- 
tion to the diagnosis and correct understanding of diseases of other 
organs; and as both the physician and the ophthalmologist should 
comprehend the mutual relations of such affections, both in diagno- 
sis and treatment, I have been led to add to my text-book on diseases 
of the eye a second part to cover the relations of the eye and its dis- 
eases to diseases of the rest of the bodj-. While these relations are 
usually more or less referred to in text- books, they are not set forth 
with such particularity as is often to be desired. 

This second part may, on the other hand, serve as a supplement to 
ordinary handbooks on general medicine which include ophthalmol- 
ogy. Since Forster dealt with this subject in the " Handbook of Oph- 
thalmology " by Graefe and Saemisch sixteen years ago, these two 
fields have not been conjointly cultivated; ' the work by Jacobson is 
constructed on different principles. The present book will for this 
reason perhaps be of value to many. 

In view of the wealth of material it has been impossible, and it 
has not been intended, to include all that might be said, lest the book 
become unwieldy and unacceptable. In selecting material there 
might be a variety of methods. It has been my aim in the first place 
to speak of diseases from a general standpoint, setting forth in sepa- 
rate sections their common and familiar features, and in the second 
place not merely to catalogue a more or less numerous array of dry 
facts, but to learn their meaning in the broadest and most complete 
sense. I frequently have to point out how eye symptoms apparently 



* The treatise in French of Berger came to my attention while this manu- 
script was passing through the press, and could not be suitably considered. 



VI PREFACE TO THE GERMAN EDITION. 

insignificant sometimes lead to far-reaching deductions concerning 
the primary and originating affection. 

It has always been a favorite study with me to trace the relation- 
ship between diseases of the eye and diseases of the rest of the body, 
and during my long association with the late Professor Horner of 
Zurich, who was a general physician as well as an oculist, I had 
abundant opportunity for such obseivations, and have since his death 
diligently pursued them. I venture to think that these studies have 
not been without value, and hope to have brought to the notice of 
my colleagues much that is new. 



CONTENTS. 



CHAPTER I. 



PAGE 

Diseases of the Nervous System, .... 1 

A. Anatomical Course of the Nerves of the Eye, . . . . . .2 

1. The Optic Nerve, 2 

3. Course of the Motor Kerves, 16 

3. Course of the Sensory Nerves, ........ 25 

B. Disorders in the Domain of the Ocular Nerves and their Central Origin, . 27 

1. Optic Nerve, 27 

A. Peripheral Visual Disorders 28 

B. Intermediate Visual Disorders, 43 

C. Cortical Disorders of Vision, 57 

2. Disorders of the Voluntary Ocular IMuscles 69 

3. Transcortical Disorders of Vision 86 

4. The Frontal Brain, 104 

5. Disorders in the Domain of the Sensory Nerves, .... 107 

6. Disorders of the Involuntary Muscles of the Eye and of the Sym- 

pathetic 109 

C. Relations between the Blood-Vessels and the Eye, 123 

D. Relations between the Eye and the Lymphatics, 127 

E. Individual Diseases of the Brain, Cord and Nerves 130 

1. Diseases of the Brain, 130 

Aneemia and Hyperaemia of the Brain and its Membranes, . 130 
Cerebral Hemorrhages, . . . . . . .131 

Embolism and Thrombosis, . 135 

Abscess of the Brain, 136 

Tumors of the Brain, 138 

Meningitis, 150 

Insanity, 159 

Paretic Dementia, 164 

Paralysis Agitans ; Diffuse Encephalitis, ..... 170 

Cheyne-Stokes Breathing ; Injuries to the Brain, . . . 171 



X 



Vlll CONTENTS. 

PAGE 

Porencephaly, 175 

Bulbar Paralysis and Allied Diseases, 176 

Multiple Sclerosis, 179 

2. Diseases of the Spinal Cord, 183 

Tabes Dorsalis, 183 

Injuries of the Spinal Cord, 199 

Trophoneuroses, .......... 200 

3. Diseases of the Nerves, 204 

Multiple Neuritis, 204 

Diseases of the Trigeminus, 206 

Diseases of the Facial Nerve, 211 

4. Functional Neuropsychosis, 211 

Hysteria, 212 

Traumatic Neurosis, . . 224 

Hypnosis and Sleep, 226 

Neurasthenia, .......... 281 

Hypochondria ; Fipilepsy, 238 

Migraine and Scintillating Scotoma, . . . . . . 237 

Chorea, 240 

Athetosis, 241 

Tetanus; Tetany, 242 

Thomsen's Disease, 244 



CHAPTER II. 
Diseases of the Skin, 246 

CHAPTER HI. 
Diseases of the Digestive Orga.ns, . . . .265 

CHAPTER IV. 
Diseases of the Respiratory Organs, .... 274 

1. Diseases of the Nose, 274 

2. Diseases of the Cavities, 279 

3. Ear Diseases, 280 

4. Effects of Respiration and its Abnormalities upon the Eye, . . . 283 

5. Diseases of the Respiratory Tract Proper, 286 



i 



CONTENTS. ix 
CHAPTER V. 

PAGE 

Diseases of the Circulatory Organs, . . .288 

CHAPTER VI. 

Diseases of the Urinary Organs, .... 299 

CHAPTER VII. 
Diseases of the Sexual Organs, . . . .311 

CHAPTER VIII. 

Poisons and Infectious Diseases, .... 324 

A. Poisons, ... , . . . .324 

B. Infectious Diseases, 360 

Septicaemia ; Pyaemia, 368 

Extensive Burns ; Glanders, 370 

Ulcerative Endocarditis ; Splenic Fever ; Tetanus and Lyssa, . . 371 

Rheumatism, 372 

Measles, 374 

Roetheln, Scarlatina, 376 

Small-pox, 378 

Vaccination, 380 

Varicella ; Typhoid Fever, 381 

Typhus Fever ; Relapsing Fever, 384 

Cholera, 386 

Dysentery ; Diphtheria, ....... . 389 

Influenza, - 392 

Whooping-Cough, . 396 

Mumps, 398 

Pest and Yellow Fever ; Beri-Beri ; Vertige Paralysant, . . . 399 

Pellagra, 400 

Malaria, 401 

Trichinosis ; Syphilis, . 404 

Tuberculosis and Scrofula, 420 

Leprosy, 425 

CHAPTER IX. 

Constitutional Diseases, 428 

Anaemia, 429 

Plethora, Corpulence, Obesity, 430 



X CONTENTS. 

PAGE 

Chlorosis, , ... 433 

Haemophilia; Addison's Disease, . , 433 

Diabetes, , „ . 434 

Diabetes Insipidus, . 440 

Basedow's Disease, 441 

Myxoedema, 445 

Rachitis, . . . . . . . , 446 

Leukseniia, 448 

Tumor Cachexia, 451 



THE RELATIONS OF THE EYE AND ITS DISEASES 
TO THE DISEASES OF THE BODY. 



CHAPTER I. 
DISEASES OF THE NERVOUS SYSTEM. 

The relations between the eye and nervous system are mutual. 
It is rare to find eye diseases the starting-point for diseases of the 
nervous system. Much more frequently diseases of the nervous 
system, especially of the central organs, cause disorders of the eye. 
These may be of a functional character or may be objectively 
visible, such as stasis, inflammation and atrophy of the optic nerve, 
exophthalmus, spasm and parah^sis of the ocular muscles, etc. The 
functional disturbances of the eye often constitute important local 
symptoms and are indispensable in the local diagnosis of brain 
diseases. On the other hand the changes visible with the ophthal- 
moscope in the optic nerve, retina, vitreous body, etc., are of a more 
general character, and usually enlighten us rather as to the character 
than the location of the disease of the brain. 

Before entering into details it is necessary to trace, as accurately 
as possible, the anatomical connection between the eye and the ner- 
vous system. This is effected by means of nerves, blood-vessels and 
lymphatics ; in addition, the cerebral meninges pass directly into the 
sheath of the optic nerve and indirectly into the coverings of the 
eye. In our description we shall consider the structures in the order 

named. 

1 



A 



THE EYE IN RELATION TO DISEASE. 



A. Anatomical Course of the Nerves of the Eye. 

We are to consider the optic nerve, the nerves of the ocular mus- 
cles, the trigeminus, facial, and sympathetic nerves. Of these by- 
far the most important is 

1. The Optic Nerve. 

This collects the centripetal and centrifugal fibres from the nerve- 
fibre layer of the retina, undergoes partial decussation in the chiasm 




Fig. 1.— Field of Vision of Both Eyes (Schematic), i, Left; B, right half of the field of 
vision, divided by the vertical line ah which passes through the point of fixation F. The ver- 
tical strip is the overlapping portion of the field of vision. 

with the nerve of the opposite side, and sends fibres through the 
optic tracts to both cerebral hemispheres. The fibres from the inner 
(nasal) half of the retina (corresponding to the outer [temporal] half 
of the field of vision) form the larger part of the nerve and undergo 
decussation. The fibres from the outer half of the retina, and which 
answer to the nasal side of the field, pass without decussation to the 
cerebral hemisphere of the same side. The optic tract thus contains 
all the fibres from the halves of the retinae on the same side, the 
right tract containing the fibres of the right retinal halves (the tem- 



DISEASES OF THE NERVOUS SYSTEM. 3 

poral half of the right eye and the nasal half of the left eye). Both 
together supply the left half of the field of vision, so that the right 
tract corresponds to the binocular left half of the field of vision and 
vice versa. Hence there is complete decussation so far as regards 
what is seen to the right and left. 

But this is only the general course, and the conditions in detail 
are much more complicated. In the first place it is to be noted that 
the line of separation between the two halves of the field of vision, 
which passes vertically through the point of fixation (not through 




Fig. 2.— Course of the Fibres in the Right Retina, Seen from in Front. E, Optic nerve en- 
trance ; F, fovea centralis ; T, external (temporal) ; V, internal (nasal) side. From the strip 
AB, corresponding to the overlapping portion of the field of vision, spring crossed (light lines) 
and uncrossed (heavy lines) fibres. 



the entrance of the optic nerve) is usually not a sharp line. As 
shown in Fig. 1, fibres from both halves of the field of vision pass 
from one side to the other in a strip which may be 10° in width 
(overlapping part of the field of vision). Hence, in loss of the region 
of destination of one optic tract, the boundary of the visual field 
usually passes to the inside or outside of the point of fixation, and 
the latter remains intact in both eyes. Fig. 2 gives the probable dis- 
tribution of the fibres of the optic nerve in the retina of the right 
eye. E indicates the point of entrance of the optic nerve, F the 



^o 



4 THE EYE IN RELATION TO DISEASE. 

point of fixation, A B the vertical strip, including the point of 
fixation, which probably sends fibres to both halves of the brain. 

In some cases of hemianopsia the boundary passes exactly through the point 
of fixation, in others there is merely a slight projection of the intact half of the 
field of vision at the point of fixation and enclosing the latter. In still other 
cases the boundary is more or less oblique or not perfectly homonymous, i.e., 
somewhat incongruent in both eyes. The causes of these differences are un- 
known, and can only be conjectured. It is evident that we have to deal, at least 
in part, with individual peculiarities. We will return to this subject again. 

The fibres which start from the macula form, as shown in Fig. 2, 
a triangular bundle on the outside of the optic papilla. As can be 
seen in the schematic sections of the optic nerve 
in Fig. 3, a d (the first immediately behind the 
eye, the last from the region of the optic fora- 
men), the fibres from the macula pass gradu- 
ally to the middle of the optic nerve. The 
same sections show that the uncrossed fibres 
(denoted by the horizontal lines) which come 
from the outer half of the retina are arranged 
at first in two crescentic bundles on the inside 
and above, and on the outside and below ; f ar- 
„ _ „ ther back they gradually coalesce into a single 

Fig. 3.— Transverse Sec- J i=> j o 

tion of the Right Optic buudlc, which, in the neighborhood of the chi- 

Nerve, Seen from in Front ; , t i • p • i 

a, in the region of the asm, lies to the insidc and a little interiorly. 

lamina cribrosa; &, in the 

optic foramen. The mac- The course of the macular fibres in the optic nerve 

ular fibres are shaded ver- ^g^g gj,g^ demonstrated by Samelsohn {Arch. f. Ophthal. , 
cSl'L'i t ZZT^ XXVII, 1) . aM subsequently confirmed by Nettleship, 
pier), horizontally. A, Vossius, Uhthoff, Bunge. The course of the fibres of 
external; J, internal. the outer half of the retina is given according to 

Schmidt-Rimpler {Arch. f. Augenheil'k., 1888, p. 296), 
who was enabled to demonstrate them in a case of "cortical hemianopsia with 
secondary optic atrophy. " These agree with Wernicke's statements ("Lehrb. d. 
Gehirnkhtn. , " I, p. 75) . According to Siemerling {Arch. f. Psych, u. Nerven- 
heilk. , Vol. XIX) the uncrossed fibres lie within the optic nerve to the outside 
(laterally) . This writer agrees with the majority of other observers, and also 
with my own observations. It is evident that in this respect there are also in- 
dividual peculiarities. 

A decussation of the fibres coming from the larger inner halves 
of the retinae takes place in the chiasm. There is partial decussation 
of the fibres from the fovea centralis and also of those coming from 



DISEASES OF THE NERVOUS SYSTEM. 5 

the previously mentioned (Fig. 2) vertical strip which is common to 
both halves. The fibres from the outer half of the retina run a direct 
(uncrossed) course, chiefly in the outer and upper part of the 
chiasm. In addition there are usually manifold intertwinings of 
the individual nerve bundles, which are very imperfectly know^n, 
and interfere notably with the study of the course of the fibres. 
These evidently constitute individual peculiarities. 

According to Siemerling (Z. c.) the uncrossed bundle in the chiasm is 
situated to the side, in the anterior part on the lower (ventral) surface and 
gradually passing upward (dorsal). According to F. Bernheimer (Arch. f. 
Aiigenlieilk., XX, 1, p. 133), this bundle passes along the upper half of the 
chiasm. In one case I was able to ascertain that immediately behind the chiasm, 
it lay to the inside in the optic tract. As a general rule it is evident that the 
direct bundle from the outer hajlf of the retina passes through the optic nerve and 
chiasm in such a way that immediately behind the latter it reaches a position 
to the outside and above in the optic tract. 

The macular fibres decussate only in great part and are situated 
centrally at the beginning of the optic tract as well as in the deeper 
part of the optic nerve. 

In addition the chiasm contains two systems of fibres which pass 
from one optic tract to the other and have no connection with the 
eye, but connect homonymous parts of the right and left halves of the 
brain. These form the commissure of Gudden, which is about one- 
third the mass of the entire chiasm, and is situated posteriorly and 
above, while the much smaller Meynert's commissure is situated in 
the upper part of the chiasm. The bundles in these commissures, 
especially in Gudden 's, frequently mingle at their borders with 
adjacent visual fibres, and thea a sharp anatomical differentiation 
cannot be made. 

The course mentioned corresponds in the main to the investigations of Gud- 
den {Arch. f. Ophth. , XXV) and at the present time probably finds general ac- 
ceptance. A very few writers, Michel in particular, still support the notion of 
the total decussation of the fibres of the optic nerve in the chiasm. Michel's 
views, last presented in detail in his treatise, " Ueber Sehnervendegeneration 
undSehnervenkreuzung, " Wlirzburg, 1887, have recently been attacked violently 
by Darkschewitsch (Arch. f. Ophth., XXXVII, 2, p. 1). 

As we shall see later, physiological and clinical data are entirely 
incompatible with the assumption of a total decussation of the sen- 
sory optic nerve fibres in man. The best proof of partial decussation 



6 THE EYE IN RELATION TO DISEASE. 

is furnished by Weir Mitchell's case {Journal of Nervous and 
Mental Disease^ 1889, p. 44), in which an aneurism had entirely 
divided the chiasm in the median line. The outer half of the retina 
of each eye retained the power of vision, while complete blindness 
would have resulted in the event of total decussation in the chiasm. 

In man, Gudden's commissure contains fibres which appear 
exactly the same as those of the remainder of the chiasm. In the 
rabbit the former are finer than the others, and in the mole they are 
the only ones present (Wernicke). The fibres of Meynert's com- 
naissure are larger than those of the remainder of the chiasm. 

In the optic tract the fibres of the crossed bundles, according to 
Wernicke, pass below the others ; those of the direct bundles pass 
through the middle, forming, on section, a transverse band through 
the entire diameter of the tractus. According to Siemerling (I. c), 
on the other hand, the direct bundle is central and at no place does it 
reach the periphery. In the vicinity of the chiasm and in the 
anterior half of the tractus the crossed and uncrossed fibres may run 
a more or less separate course, but farther posteriorly their complete 
intermingling is a physiological necessity. Upon entering the cere- 
bral ganglia they are intermingled in such a way that every part of 
the tractus represents corresponding parts in both retinse. The 
macular fibres can only be occasionally demonstrated close to the 
chiasm as a central distinct bundle (Uhthoff, Arch. f. Ophth., 
XXXII, 4), farther backward they are not distinguishable. An 
excellent resume of the views of different investigators on the course 
of the fibres in the optic nerve, chiasm and optic tract is found in 
Wilbrand's work, "Die Hemianopischen Gesichtsfeldformen," 
Wiesbaden, 1890, p. 48 et seq. 

It has been positively proven that the visual fibres of the optic 
tract have a threefold termination. The main part enters the 
external geniculate body; other bundles pass to the pulvinar, 
thalami optici and to the anterior corpora -quadrigemina. These 
three structures are called the primary optic ganglia. From all 
three can be traced bands of fibres which pass to the posterior third 
of the internal capsule (between the lenticular nucleus and optic 
thalamus) and thence proceed as Gratiolet's optic radiations to the 



DISEASES OF THE NERVOUS SYSTEM. 




cortex of the occipital lobe, especially to its posterior parts and to the 
cuneus. Fig. 4 gives a schematic illustration, according to Wer- 
nicke, of the principal conditions. 

The arm (brachium) of the anterior corpora quadrigemina con- 
sists of fibres of the optic tract passing to this ganglion, and of the 
fibres of the corona radiata 
which pass from it to the 
cortex of the occipital lobe. 
In addition it furnishes a 
few fibres to the posterior 
commissure of the brain. 

From the anterior cor- 
pora quadrigemina pass (or 
enter) numerous fibres 
which decussate in the roof 
of the aqueduct of Sylvius 
and then enter the so-called 
fillet which passes in the 
tegmentum of the cerebral 
peduncle to the optic thala- 
mus. Meynert has also de- 
monstrated association fibres to the nuclei of the ocular muscles 
(Meynert 's fibres). 

Gudden's commissure connects both internal geniculate bodies 
and the posterior corpora quadrigemina and sends a bundle directly 
into the corona radiata of the occipital lobe on the same side. A free 
decussation of fibres also takes place between the posterior corpora 
quadrigemina ; these also send a bundle of fibres to the fillet. To 
judge from its terminations Gudden's commissure seems to be con- 
nected with hearing, and in a certain measure to constitute an audi- 
tory chiasm. It remains intact after the loss of both eyes. This 
view is also favored by the fact that the ganglion cells of the inter- 
nal geniculate body degenerate after extirpation of the cortex in the 
temporal lobes (Monakow). 

Me3^nert's commissure lies only upon the median half of the trac- 
tus, enters the cerebral peduncle from below, and is lost in the latter. 



Fig. 4.— Schematic Diagram of the Termination of 
the Tract, after Wernicke. To, Optic tract; GC, Gud- 
den's commissure of the same; Cge, external genicu- 
late body; Cfir/, internal geniculate body; Cga, anterior 
corpus quadrigeminum ; Cgjo, posterior corpus quadri- 
geminum ; P, pulvinar of the optic thalamus ; G, fibres 
of the corona radiata of the occipital lobe (Gratiolefs 
visual fibres); AS, aqueduct of Sylvius; H, tegmen- 
tum; Sn, substantia nigra; F, pes pedunculi. 



8 THE EYE IN RELATION TO DISEASE. 

It is arranged in loose bundles and consists of larger fibres, with a 
greater amount of medulla than the others in the chiasm. This 
commissure is probably connected with the so-called Luys' bodies, 
which are situated immediately below the optic thalamus. 

The roots of the tractus from the internal geniculate bodies, 
Luys' bodies, etc., mentioned by Hernheimer (" Ueber die Sehnerven- 
wurzeln des Menschen," Wiesbaden, 1891) may be referred with cer- 
tainty to these two commissures and hence possess no direct relations 
to the visual organ. Other tractus roots, which may even be traced 
into the spinal cord (Stilling) are still very uncertain anatomically, 
but their existence, as we shall see later, is a physiological necessity. 
It is not necessary, however, that such fibres, or those which pass to 
the cerebellar peduncles, etc., must run their course in distinct bun- 
dles. The opposite condition appears to hold good, and hence such 
fibres escape direct anatomical demonstration. The latter would be 
very desirable in all cases, but is not absolutely necessary to prove 
the existence of connecting fibres. 

Thus far it is possible to follow the visual tracts directly, but 
their further course to the cerebral cortex must be inferred clinically 
and experimentally. It is certain that adjacent convolutions of the 
cerebral cortex are connected with one another by systems of so- 
called association fibres which lie directly beneath the gray matter, 
and that between all the cerebral lobes of one side there are other 
association fibres, whose bundles run more deeply in the medullary 
substance. The latter include the gyrus fornicatus and uncinate 
gj^rus. The "visual sphere" of the occipital lobe, into which 
Gratiolet's optic radiations enter, is thus connected by associating 
fibres with the cortex of the temporal, parietal, and frontal lobes of 
the same side. Great importance attaches to the connection of the 
left occipital lobe with Broca's convolution of the left frontal lobe on 
account of the relations of the latter to speech. For purely topo- 
graphical reasons this must run its course deep within the inferior 
parietal convolution. Inasmuch as there are also connections be- 
tween homonymous parts of the cortex of the two hemispheres by 
means of the different commissural systems (of which the corpus 
callosum is the most important), it may be maintained that every 



DISEASES OF THE NERVOUS SYSTEM. 9 

part of the cortex stands in direct or indirect mutual connection with 
every other part, although our knowledge of the precise course of 
these fibres leaves much to be desired. 

The association and commissural systems of fibres are simply 
connections of the different parts of the cortex with one another. 
The centripetal and centrifugal connection of the cortex with the 
rest of the brain is effected solely by the corona radiata, which are 
collected, from and to tlie entire cerebral cortex, in the internal cap- 
sule between the lenticular nucleus and optic thalamus. Those 
fibres which pass to and from the occipital cortex (Gratiolet's optic 
radiations) are situated in the posterior third of the posterior limb 
of the internal capsule, immediately adjacent to the centripetal sen- 
sory tract. 

In order to juage correctly the experimental investigations on the 
course of the fibres in the brain — the results of which have been 
made to lead to some extent to antagonistic conclusions — the fol- 
lowing points must be kept in mind. According to the best recent 
investigations two ganglion cells are never connected directly by an 
axis-cylinder process, but the axis cylinders which originate from 
ganglion cells in one place are resolved, at the other extremity, into 
a fine network, in which lie other ganglion cells, and these in turn 
again send out axis cylinders. The other processes (viz., the proto- 
plasmic) of ganglion cells likewise do not pass directly into one 
another, but are merely intertwined in the most complex manner. 
Kot all ganglion cells give origin to an axis cylinder, but there are 
some whose processes terminate in a fine network of fibres (Golgi's 
ganglion cells of the second order). 

The connective-tissue neuroglia is found between the nerve fibres 
of the brain and peripheral nerves. The ganglion cells and the 
interlacing network of finest fibres (neuropilemma of His) in the 
cerebral cortex lie in a fine supporting network (neurospongium of 
His) of originally epithelial origin. 

If a nerve is permanently divided or destroyed in the adult, its 
fibres degenerate as far as the finest terminal network. The degen- 
eration also involves those ganglion cells whose axis- cylinder 
processes pass through the corresponding nerve. It is only at a late 



10 THE EYE IN RELATION TO DISEASE. 

period, and then not constantly, that other groups of ganglion cells 
and systems of fibres become affected. In my opinion, cases of the 
latter kind are those in which a more or less inflammatory degener- 
ative process extends along the preformed tracts of the nerve fibres, 
i.e.^ we have to deal with a complication. The less the degree of 
secondary degeneration the more important and correct are the 
results of the experiment or of the clinical observation. 

The conditions are more complicated when the cerebral cortex is 
destroyed. Apart from the supporting mesh work (neurospongium) 
this contains: 

1. The mesh of nerve fibres (neuropilemma) : 

a, of the centripetal fibres of the corona radiata ; 

6, of the fibres of the commissures and associative systems which 

break up at the part in question ; 
c, of those processes of the ganglion cells which are not axis 

cylinders. 
The neuropilemma contains : 

2. Ganglion cells : 

a, whose axis cylinders enter the associative fibres and the com- 
missures and break up into a network in other parts of the 
cortex ; 
6, whose axis cylinders run a centrifugal course in the corona 
radiata ; they are generally characterized by their unusually 
large size; 
c, which only form a netw^ork (Golgi's ganglion cells of the 
second order). 
All these elements are found in every part of the cerebral cortex, 
but in varying proportions in different localities. For example, the 
large (motor) pyramidal cells, whose axis cylinders conduct centrif- 
ugally, are very abundant in the motor parts of the cortex, but are 
much more scanty in the sensory parts to which the occipital cortex 
also belongs. From this fact alone it may be maintained that no 
single part of the cerebral cortex is purely sensory or purely motor, 
t.e., sends out only centripetal or only centrifugal fibres. Centri- 
fugal fibres are present even in the corona radiata of the occipital 
lobe, and may even be demonstrated in the optic nerve. It is true 



DISEASES OF THE NERVOUS SYSTEM. 11 

that their course is not demonstrable anatomically, but it may be 
inferred with tolerable certainty. 

If a certain region of the cerebral cortex is destroyed, degenera- 
tion takes place, first, in the centripetal fibres of the corona radiata, in 
the associative system of fibres and the commissures whose terminal 
networks are destroyed, together with the ganglion cells from which 
they take their origin as axis-cylinder processes ; and, second, in all 
centrifugal {i.e., with reference to the cortical region in question) 
fibres of these three systems, whose ganglion cells of origin are 
destroj'ed, together with their terminal networks in other parts of 
the brain. In the latter regions those ganglion cells which are 
merely surrounded by the degenerating terminal networks remain 
intact. 

While the division of a nerve is a comparatively simple experi- 
ment, in destruction of a part of the cerebral cortex every other part 
of the cortex will be implicated, entirely apart from the destruction 
of the adjacent lower groups of ganglion cells. Other parts are not 
implicated in a uniform manner, but according to the intimacy of 
connection with the destroyed region. 

In associative and commissural fibres degeneration can com- 
monly be demonstrated only when they are arranged in separate 
bundles. The degeneration, which affects only certain elements of 
the neuropilemma, cannot be discovered by the microscope, except 
in very recent cases. 

After division or degeneration of the optic nerve in an adult, 
atroph}^ takes place, first, in the ganglion-cell layer of the retina 
(ganglion optici), whose axis-cylinder processes constitute the main 
part of the fibres of the optic nerve; and, second, in a group of gan- 
glion cells in the superficial gray matter of the anterior corpora 
quadrigemina, perhaps of both sides but at all events chiefly on the 
opposite side (Monakow) . Hence, the latter must contain centrifugal 
axis-cylinder processes destined to the optic nerve. 

In the other so-caUed primary optic ganglia, viz. , the external 
geniculate body, the zonal stratum of the optic thalamus (the pul- 
vinar) and the remaining parts of the anterior corpora quadrige- 
mina, we find merely atrophy of the medullaiy layer, while the 



12 THE EYE IN RELATION TO DISEASE. 

ganglion cells remain intact. Whether single ganglion cells are 
destroyed in other localities, cannot be determined. 

In destruction of both optic nerves or of the chiasm the lesions 
are bilateral; in destruction of one tractus the above-mentioned 
ganglion cells of the anterior corpus quadrigeminum on the same side 
and the ganglion cells of both retinal halves on the same side will 
undergo atrophy. In addition certain groups of ganglion cells 
which belong to Meynert's and Gudden's commissures also undergo 
atrophy after destruction of the chiasm or of one tractus. 

What has been stated is true of non-progressive processes and of 
experiments performed as aseptically as possible. If the'degenerative 
process (perhaps it may be infectious) spreads farther along the 
atrophic nerve fibres, the ganglion cells of the primary optic ganglia 
may also be destroyed in part or entirely, and then the fibres of the 
corona radiata maj^ undergo degeneration. Indeed, the atrophy 
may even be noticeable as far as the occipital cortex (cases reported 
by Huguenin, N"othnagel, Kowalewski, Giovanardi, Tomaschew- 
ski, etc.). This is undoubtedly very rare in adults. It is possible, 
however, that after atrophy of the optic-nerve fibres of very long 
standing, visible atrophy will finally occur in the more central parts, 
because their function is not sufficiently exercised. But the assump- 
tion of a progressive process is more probable even in such rare 
cases. When, after atrophy of the optic nerve, atrophy has also been 
found at a comparatively early period in the primary optic ganglia 
(for example, in tabes and the like) , we cannot reject the notion that 
these ganglia may have been affected primarily and that the optic 
nerve, whose centripetal neuropilemma was destroyed, has undergone 
secondary atrophy. Moreover, both may have been attacked at the 
same time. Compare, for example, Eichter, Archiv fiir Psychiatrie 
und Nervenheilkunde, XX, p. 504. 

From the statements made it follows that the optic nerve con- 
tains at least two different kinds of fibres, viz., those which are axis- 
cylinder processes of the ganglion-cell layer of the retina (ganglion 
optici), and those whose cells of origin are situated in the anterior 
corpora quadrigemina, possibly also in other parts of the brain. 
Two kinds of fibres may also be distinguished anatomically in the 



DISEASES OF THE NERVOUS SYSTEM. 13 

optic nerve, viz. , finer and coarser ones ; both are present in approx- 
imately equal numbers. The former are the axis-cylinder processes 
of the ganglion cells of the retina, the latter are derived in great 
part from the anterior corpora quadrigemina and break up into a fine 
network, particularly in the internal granular layer (ganglion retinae). 
It is an interesting fact that in the ejes of mussels these two parts of 
the optic nerve pass to the retina as separate bundles (vide Rawitz, 
Jenaische Zeitschrift f. Nattiriviss., Bd. XXII and XXIV). 

Hence it follows necessarily that either the axis-cylinder pro- 
cesses conduct centripetal and centrifugal stimuli or that conduction 
in the optic nerve takes place in two opposite directions. The 
former appears improbable, so that the second assumption must be 
the correct one, i.e., the optic nerve contains in approximately equal 
numbers coarser fibres which conduct centrifugally and finer ones 
which conduct centripetally. It is possible that a nerve fibre may 
conduct in both directions, but such an assumption with regard to 
the optic nerve is unnecessary under existing circumstances. 

It is to be noted that the optic nerve may not be compared un- 
reservedly with a peripheral sensory nerve. The retina is an outly- 
ing part of the cerebral cortex. Hence the optic nerve might, with 
equal propriety, be interpreted as a system of association fibres 
between two parts of the brain, which conduct stimuli in both 
directions and everywhere constitute a mixture of afferent and 
efferent axis-cylinder processes. 

The number of fibres in the optic nerve is variously estimated : by Salzer at a 
little more than 400,000 ; by Krause at this number of coarse fibres and an equal 
number of finer fibres ; by Kuhut, at about 40,000 (i.e., only one-twentieth of 
Krause 's figures) . At all events the number is considerably less than that of the 
retinal cones which are estimated by Salzer at about three and one-third millions ; 
i.e., about eight bacilli to one centripetal fibre of the nerve. 

There does not appear to be any dichotomous division of the separate fibres in 
the optic nerve, but there are numerous intertwinings and anastomoses between 
the different bundles. According to Michel this is particularly true in the 
retina and also as they approach the chiasm. 

When the occipital cortex is destroyed, its coronal fibres 
atrophy, together with the majority of the ganglion cells of the 
external geniculate body, of the stratum zonale of the optic thalamus, 
and those cells in the anterior corpus quadrigeminum (Monakow) 



14 THE EYE IN RELATION TO DISEASE. 

which remain intact after division of the optic nerve. The same 
ganglion cells also degenerate when the corona radiata of the occip- 
ital cortex alone is divided. These groups of cells evidently send 
their axis -cylinder processes to the occipital cortex, where they end 
in a fine network. Those fibres of the tractus which pass to the 
primary optic ganglia also terminate there in a network. In part, 
however, they merely pass through or alongside the network, and it 
is impossible to demonstrate their further anatomical course. 

Destruction of the occipital cortex destroys a large number of gan- 
glion cells which send axis cylinders into the association fibres and 
cerebral commissures, and likewise the terminal networks of axis 
cylinders which are derived from the cells of other parts of the 
brain. All divided fibres and the corresponding ganglion cells will 
be destroyed. It is only in the immediate neighborhood of destroyed 
cortical regions that the association fibres are grouped in imperfect 
bundles. Monakow observed degeneration of association fibres only 
in an anterior direction, toward the parietal lobes. 

Hence, the distinctly visible atrophy after destruction of the cor- 
tex of one occipital lobe is confined to the corresponding part of the 
corona radiata and to the ganglion cells of the three primary optic 
ganglia on the same side, with the exception of those in the anterior 
corpora quadrigemina, which send out centrifugal fibres to the optic 
nerve. The degeneration cannot be traced farther into the periph- 
ery, nor is atrophy of the disc visible with the ophthalmoscope, even 
after the lapse of many years. It is only in a few cases that visible 
changes are finally seen in the tractus, chiasm, and optic nerve. 
Such rare cases are probably due to the extension of a degenerative, 
inflammatory process which, after destruction of the ganglion cells, 
also attacks the terminal network of the optic-nerve fibres in the 
primary optic ganglia, and then leads to degeneration of the fibres 
of the tractus and optic nerve, and later the ganglion cells of the 
retina. This is analogous to the previously mentioned cases (page 
12), in which destruction of the optic nerve causes visible atrophy 
in the occipital cortex (vide Monakow, Corr. Blatt /. Schweizer 
Aerzte, 1, VI, 88, p. 346). 

All the statements hitherto made hold good only in regard to 



DISEASES OF THE NERVOUS SYSTEM. 15 

adults. In the new-born the conditions are entirely different. In 
them it is evident that many combinations of fibres, which exist in 
the adult, have not yet developed. The investigations of Bern- 
heimer showed that in the new-born the optic nerve and chiasm 
contain only a limited number, of medullated fibres. According to 
Flechsig's well-known assumption, they are only partly capable of 
function. If one eye or both eyes are destroyed at this period the 
degenerations are much more extensive. The ganglion cells of the 
primary optic ganglia degenerate almost completely. In the cortex 
of the occipital lobe much less is noticeable, very probably because, 
at this time, it is insiifficiently connected with the primary optic 
ganglia and to a certain extent is still "indifferent." In the further 
development of the brain the occipital cortex appears to assume other 
functions, probably on account of the more marked development of 
the system of association fibres, and the entire distribution of the 
cortical regions becomes different. It is probable that the auditory 
and particularly the tactile sense acquires a much larger cortical 
area. But these are . merely assumptions which follow in part from 
the observations of cases of congenital blindness. 

To make a brief resume^ we find in the optic nerve two kinds of 
fibres in approximately equal numbers: a, narrow centripetal axis 
cylinders from the ceUs of the ganglionic layer of the retina, which 
terminate, in great part, in a fine network in the three primary optic 
ganglia ; and &, thicker centrifugal axis-cylinder processes from the 
ganglion ceUs of the anterior corpora quadrigemina, which spread 
out in the internal granular layer of the retina. The remaining 
ganglion cells of the primary optic ganglia send their axis-cylinder 
processes (in the posterior third of the posterior limb of the internal 
capsule, immediately adjacent to the centripetal sensory tracts of the 
corona radiata) to the cortex of the occipital lobe, especially to the 
cuneus. The association fibres of the occipital cortex mainly pass 
forward. [The investigations of Henschen ("Klinische und ana- 
tomische Beitrage zur Pathologie des Gehirns," Upsala, 1892, 
zweiter Theil) have narrowed the region of primary and direct corti- 
cal visual impressions to the calcarine fissure which is the inferior 
boundary of the cuneus. — N.] 



16 



THE EYE IN RELATION TO DISEASE. 



2. Course of the Motor Nerves. 



The motor nerves connected with the eye are: the motor oculi 
communis, trochlearis, abducens, facial, and, to a certain extent, 
the sympathetic. The trochlearis and abducens each supplies a 
single external ocular muscle, the former the superior oblique, the 
latter the external rectus. The motor oculi innervates the remain- 
ing external ocular muscles and the levator palpebree superior is. In 
addition it contains the fibres for the sphincter pupillse and the 
ciliary muscle. The facial innervates the muscles belonging to the 
eye which are situated outside of the orbit, particularly the orbicula- 
ris palpebrarum. The portion of the facial nerve which supplies this 
muscle and the frontal muscle is often called the ocular facial. The 

sympathetic contains fibres 
for the dilator pupillse [if 
such a muscle exists — N.l, 
the so-called Mueller's mus- 
cle, which moderately di- 
lates the palpebral fissure, 
and for muscular fibres 
which lie in the fascia that 
closes the inferior orbital 
fissure; all of these are 
smooth muscular fibres . As 
a matter of course there are 
also nerve fibres for the mus- 
cular coats of the vessels. 

The paths of the motor 
nerves from the eye to the 
brain lead, apart from the 
sympathetic, to nuclei in 
the neighborhood of the aqueduct of Sylvius and in the floor of the 
fourth ventricle. Fig. 5 gives a schematic representation of their 
approximate grouping (after Magnus). 

a. The motor oculi communis passes from its nucleus through 
the cerebral peduncle (posterior longitudinal bundle and red nucleus) 




Fig. 5. 



-Nerve Nuclei of the Motor and Sensory Cere- 
bral Nerves (after Magnus). 



DISEASES OF THE NERVOUS SYSTEM. 17 

in a wavy and scattered course, and emerges from the innermost 
bundles of the peduncle, immediately in front of the pons. It 
passes between the posterior cerebral and superior cerebellar arteries 
obliquely outward and forward, and then to the upper and outer 
wall of the cavernous sinus, where it receives a few filaments from 
the carotid plexus. Dividing into two branches it then passes 
through the superior orbital fissure at the outer side of the optic 
nerve. The upper, smaller branch supplies only the levator palpebrse 
superioris and the superior rectus, the other supplies the remaining 
muscles, the internal and inferior recti and the inferior oblique. 

The nucleus of the motor oculi lies between the posterior longi- 
tudinal bundle (the tegmentum of the peduncle) and the aqueduct of 
Sylvius, and extends from the posterior extremity of the third ven- 
tricle beneath the anterior corpora quadrigemina to a point beneath 
the posterior corpora quadrigemina. It consists of an accumulation 
of multipolar ganglion cells, some of which are closely aggregated, 
others are more scattered, and those from each side come in contact 
on the median line. Some of the ganglion cells are situated be- 
tween the fibres of the posterior longitudinal bundle. Shortly after 
emerging from the lower and outer side of the nucleus the root fibres 
anastomose freely with one another. The constitution of this nucleus 
is very complicated, and in the main we follow the description of 
Perlia, who has published the most recent and exhaustive account 
of it {Archiv f. Ophthalmologie, XXXV, 4, p. 289 et seq. Fig. 6 
follows his scheme). 

We may distinguish an anterior smaller (1-2) and a posterior 
larger portion (3-8), In the larger nuclear mass is a central group 
in which the ganglion cells from both sides meet beneath the aque- 
duct of Sylvius (Perlia 's central nucleus 8) and a lateral division 
(4-7). In the latter Gudden has distinguished an upper (dorsal) 
portion situated a little to the outside (4, 5), and a lower (ventral) 
portion, situated to the inside (6, 7). Perlia has rendered it very 
probable that each of these parts is again subdivided into an anterior 
and posterior group. To these five groups may be added another 
(3), first seen by Edinger, and accurately described by Westphal, 
who distinguished a central and a lateral portion. It has approxi- 



18 



THE EYE IN RELATION TO DISEASE. 



niately the shape and position shown in the scheme, and its ganglion 
cells are smaller than those of all other parts of the nucleus. 

In the anterior smaller division two groups are recognized on both 
sides : a median (2) and a lateral (1) group. The latter runs ob- 
liquely outward and 
Ik r\ r\ /^ was first described by 

Darkschewitsch. Ac- 
cording to him (Arch, 
f. Anat. u, Phys., 
1889, p. 107) this upper 
nucleus (presumably of 
the sphincter pupillsB 
and the muscle of 
accommodation) pos- 
sesses smaller cells and 
sends out finer fibres 
than the other cell 
groups (with the ex- 
ception of the Edinger- 
Westphal nucleus 3). 
The fibres of this nu- 
cleus are said to pass 
along the posterior 
cerebral commissure in 
its more ventral por- 
tions, and become meduUated at an earlier period than the dorsal 
portion. They are said to be derived in part from the pineal gland, 
whose inferior medullary layer they constitute ; fibres from the loops 
of the lenticular nucleus are doubtful. According to Darksche- 
witsch the afferent fibres undergo partial decussation. According to 
Spitzka (Centralbl. f. Nervenheilk.^ 1889, p. 105) they do not. The 
anterior lateral nucleus (1) is connected with the main group by 
bands of fibres ; there is also an exchange of fibres with the anterior 
median double nucleus (2), which lies deeper and more centrally. 

The Darkschewitsch nucleus (1) is also said to derive fibres from 
the region of the brachium of the anterior corpora quadrigemina 




Fig 



-Schematic Diagram of the Nuclei of the Oculomotor 
and Trochlear Nerves. 



DISEASES OF THE NERVOUS SYSTEM. 19 

(tractus fibres) . The complexity of the oculomotor nucleus implies 
a corresponding richness in the number of its afferent fibres. We 
find a thick meshwork of fibres which start from it or go to it, curv- 
ing upward around the aqueduct through its gray matter. A prom- 
inent addition to the motor oculi nucleus is formed by the fibres of 
the posterior longitudinal bundle of the tegmentum (sensory fibres 
from the opposite side of the body) which terminate here in great 
part (in the neuropilemma). According to Flechsig and Edinger 
the fibres of the posterior longitudinal bundle, in a foetus of nine 
months, are medullated, and therefore capable of function only in 
so far as they terminate in the motor oculi nucleus, but not farther 
forward. In adults the posterior longitudinal bundle is also said to 
contain fibres from the loop of the lenticular nucleus. According to 
Meynert these represent the projection system from the hemispheres 
to the gray matter of the central canal (aqueduct). 

According to Gudden and Spitzka the motor oculi nerve takes its 
origin from the nucleus in such a way that its fibres pass out from 
the anterior division (1, 2) and the inferior part of the posterior divi- 
sion (6, 7) of the same side, and from the superior part of the poste- 
rior division (4, 5) of the opposite side. According to Perlia {vide 
the scheme) the crossed part is derived only from the posterior cell 
group (5) of the upper part of the principal nucleus, and some of the 
decussating fibres pass downv^ard in the raphe and then bend into 
the posterior longitudinal bundle ; in my opinion the latter fibres are 
centripetal. The anterior division of the superior cell group (4) 
gives origin to uncrossed fibres. 

All the axis cylinders derived from the muscle nucleus become 
fibres of the motor nerve, so that all the other fibres must pass to the 
nucleus and — if they do not merely pass through — must terminate 
there in the network. From the standpoint of the nucleus they are 
centripetal. The fibres which are positively demonstrated to be of 
this character are: 1, sensory fibres from the opposite half of the 
body, in the posterior longitudinal bundle of the tegmental region of 
the peduncle. In fact they undergo another decussation in the raphe. 
They are medullated even in the foetus. 2. Tractus fibres, corre- 
sponding to the opposite half of the field of vision, possibly inter- 



20 THE EYE IN RELATION TO DISEASE. 

rupted by ganglion cells. They come from the external geniculate 
body, passing in great part in the anterior brachium of the corpora 
quadrigemina and from the anterior corpus quadrigeminum to the 
oculomotor nucleus (Meynert's fibres). For clinical reasons and 
from the results of experiments, it is also evident that fibres of the 
corona radiata must pass to the muscle nuclei. It is very probable 
that these fibres pass, in great part, along Gratiolet's optic radiations 
and originate in the cortex of the "visual sphere." We will again 
return to this point. 

Where and how the numerous connecting fibres between the dif- 
ferent groups of nuclei begin and end can only be surmised, because 
we possess no positive data. 

The individual cell groups evidently correspond to the individual 
muscles supplied by the nerve, as was first shown by the experi- 
mental investigations of Hensen and Voelkers (Arch. f. Ophth., XIX, 
1). There is great difference of opinion regarding the details in 
man. It appears to be certain, however, that the nuclei of the 
sphincter pupillse and the ciliary muscle lie in front of the others, 
and it is very probable that the nucleus for the levator palpebrse 
superioris lies in front of those for the other voluntary muscles. 
Westphal claims that accommodation and movement of the iris are 
regulated bj^ the nucleus (3) named after him, while Darkschewitsch 
makes the same claim for the nucleus (1) named after himself. 
Both nuclei, particularly the former, are characterized by the small 
size of their ganglion cells. 

With regard to the principal nuclear mass we assume that those 
cell groups (4, 6,. 7) which send out nerve fibres on the same side 
are involved in movement of the eye to the inside, those from which 
fibres pass to the nerve of the other side (5) take part in movement 
to the outside. We then have the following distribution : Number 
6 and the central nucleus 8 correspond to the internal rectus. We 
shall hardly go astray in assuming that 8 presides over the move- 
ment of convergence and that 6, by means of its connections with the 
opposite abducens nucleus, presides over the action of the internal 
rectus in the conjugate movements of the eye. The direct conti- 
guity of the Edinger-Westphal nucleus (3) to the central nucleus (for 



DISEASES OF THE NERVOUS SYSTEM. 21 

convergence) testifies to the intimate relations of convergence and ac- 
commodation. Both are almost always associated with a movement 
downward, hence the nucleus for the inferior rectus is to be sought 
in 7 ; 4 would correspond to the superior rectus, 5 to the inferior 
oblique, both of which are concerned in the upward movement of 
the eye. Experiments and clinical observation make it probable that 
the nucleus of the superior rectus lies in front of that of the inferior 
oblique. 

Westphal assumes that 3 presides over accommodation and move- 
ments of the iris. The case from which he draws this conclusion 
(Deutsch. med. Wochen., 31, III, 87) was that of a man suffering 
from chronic progressive paralysis of the external ocular muscles; 
the pupil reacted to accommodation but not to light. At the autopsy 
the trunk and nucleus of the motor oculi were found degenerated; 
groups of ganglion cells were present only in the most anterior portions 
of the nucleus on both sides of the raphe. This case simply proves 
that accommodation was still present ; the associated movement of 
the iris occurs in a purely mechanical manner, inasmuch as the 
blood is forced momentarily into the iris by the contraction of the 
ciliary muscle. If we regard 3 as the accommodation nucleus, then 
nucleus 1 would regulate the pupillary movement by the sphincter 
pupillse (Darkschevvitsch). These assumptions agree very well with 
our previous anatomical and clinical observations and to a sufficient 
degree with those derived from experiments on animals. The latter 
only permit cautious inferences with regard to the conditions in 
man. Nucleus 2 would then be left for the levator palpebrae super i- 
oris. This muscle, in correspondence with the comparatively iso- 
lated position of its nucleus, assumes a special position, inasmuch as 
it is often paralyzed alone or is alone intact in paralysis of the motor 
oculi nerve. It is not necessary, as Mendel would infer from certain 
experiments on animals, to locate the nucleus of the " ocular facial" 
nerve in the hindmost part of the nucleus of the motor oculi. This 
is disproven by clinical experience in the human subject (vide 
Muencli. med. Wochen., 1887, p. 902). 

• The scheme adopted does not agree entirely with the well-known 
one of Kahler and Pick, in which the centre for accommodation is sit- 



22 THE EYE IN RELATION TO DISEASE. 

uated in front of that for the sphincter pupillse, but agrees very well 
with Starr's scheme {Journ. of Nerv. and Ment. Disease, May, 
1888) , which was constructed according to the doctrine of probabili- 
ties, from 20 cases of partial motor-oculi paralysis. The nucleus for 
the levator palpebrse superioris (2) lies nearer, in my scheme, to the 
median line than has been hitherto assumed (viz., corresponding 
about to the anterior portion of 4). 

Perlia's scheme agrees essentially with that of Siemerling {Arch. f. Psych, 
u. Nerv., XXII, Suppl. , p. 152). The latter is inclined to place the nucleus for 
the levator palpebrse superioris at the posterior extremity of the motor oculi 
nucleus, where he found a certain group of cells intact in a case of ophthalmo- 
plegia without affection of this muscle. This would coincide with Mendel's 
opinion. According to a more recent publication {ih. , XXIII, 3) , with regard 
to the findings in a case of congenital unilateral ptosis, he again opposes this 
view. Positive findings in an acquired unilateral ptosis alone would be con- 
vincing. In Boediker's case {Neurol. Centr., 1891, p. 187) the more posterior 
part of the motor oculi nucleus was intact, and there was no ptosis. The median 
anterior groups (my levator nucleus) were also intact. 

Hence the motor oculi nucleus of each side contains the nuclei of 
those muscles which take part in the movement of both eyes toward 
the opposite side, i.e., the internal, superior and inferior recti of the 
same eye and the inferior oblique of the opposite eye. The former 
muscles take part in movement of the eye inward, the external rec- 
tus, superior and inferior oblique take part in outward movement. 

b. The trochlearis nucleus is merely the most posterior part of 
the motor oculi nucleus ; but its ganglion cells are larger than those 
of the latter. The fibres originating in it pass backward and in- 
ward to the valve of Vieussens at the upper end of the fourth ven- 
tricle, where they decussate with those of the other side. The nerve 
emerges on the posterior surface of the valve of Vieussens, bends 
around the processus cerebri ad corpora quadrigemina and the cere- 
bral peduncle forward and inward, lies immediately beneath the 
free border of the tentorium, perforates the dura mater behind the 
posterior clinoid process, and passes through the superior orbital fis- 
sure into the orbit, where it passes above the origin of the ocular 
muscles to the superior oblique muscle. 

The root fibres for the inferior oblique also decussate, as we have 
seen above (Fig. 6, Nucleus 5). 



DISEASES OF THE NERVOUS SYSTEM. 23 

According to Siemerling (Xeurol. CentralbL, 1819, p. 188) 
Westphal's posterior trochlearis nucleus {Arch. f. Psych., XVIII) 
has nothing to do with the trochlearis nerve. According to Schnetz 
it belongs to the "gray matter of the central canal." 

c. The ahducens nucleus lies about at the middle of the floor of 
the fourth ventricle beneath its gray lining. The nerve passes for- 
ward through the pyramids of the medulla oblongata, emerges at 
the posterior border of the pons, and then passes to the posterior wall 
of the cavernous sinus, which it perforates and then extends along 
the outer side of the internal carotid ; here it is said to receive fibres 
from the carotid plexus. The nerve then passes through the superior 
orbital fissure into the orbit, perforates the origin of the external 
rectus and is lost in this muscle. 

According to Spitzka (I. c.) the posterior longitudinal bundle con- 
tains fibres which connect the abducens nucleus with the nucleus of 
the internal rectus on the same side. As the roots for the latter 
muscle do not decussate {vide scheme), this is extremely improbable, 
inasmuch as the roots of the abducens likewise do not cross. Ac- 
cording to Duval, fibres from the abducens nucleus pass to the motor, 
oculi nucleus of the opposite side, and this would correspond better 
to the actual conditions. 

d. The facial nucleus is also situated in the floor of the fourth 
ventricle, to the outside of and a little behind that of the abducens. 
Its ganglion ceUs are larger than those of the adjacent abducens 
nucleus. The root fibres encircle the latter; after being joined they 
run for some distance to the outside beneath the gray matter of the 
central canal and then bend forward (knee of the facial nerve) . The 
nerve makes its appearance at the posterior border of the pons, out- 
side of the olivary bodies, passes into a groove of the acoustic nerve, 
and then takes its well-known wa}' through the Fallopian canal of 
the petrous portion of the temporal bone. It emerges from the 
stylomastoid foramen and then ramifies in the shape of a fan into the 
muscles of the face. 

In view of the fact that in about ninety per cent of all " central" 
facial paralyses the orbicularis palpebrarum and frontalis muscles 
which are supplied by the superior facial escape, while they are 



24 THE EYE IN RELATION TO DISEASE. 

affected in peripheral paralysis, Mendel removed these muscles in 
a rabbit and two guinea pigs. In all three animals atrophy devel- 
oped in the posterior part of the motor-oculi nucleus on the side oper- 
ated upon. He is therefore inclined to believe that the nucleus of 
the ocular facial is separated from the rest of the nerve and is more 
closely related to the nucleus of the motor oculi. In the discussion 
on the question Uhthoff and Hirschberg did not accept this sugges- 
tion, at least in regard to the human subject {vide p. 21). We will 
hereafter offer another explanation for this fact. 

e. The motor sympathetic fibres of the eye are derived from the 
superior cervical ganglion and pass through the carotid plexus. 
When farther central they are governed by the lowermost part of the 
cervical cord (about at the level of the sixth and seventh cervical and 
first dorsal vertebrae). Irritation of this part causes spasm; its de- 
struction causes paralysis of the corresponding muscular fibres 
(Budge's cilio-spinal centre). The details of the course of these 
fibres, which cannot be demonstrated anatomically, will be discussed 
under the heading of muscular disorders. 

Apart from connecting fibres and decussations between the mus- 
cle nuclei of the same name on both sides (rectus internus and infe- 
rior, obliquus superior, sphincter pupillse, and probably also the 
ciliary muscle) or different muscle nuclei of the same side (abducens — 
internal rectus of the other side), the connections with cells of higher 
cerebral ganglia are known very imperfectly and in the main must 
be inferred from experiments and clinical observations. There is no 
doubt of close relationship to the primary optic ganglia (Meynert's 
fibres between the anterior corpora quadrigemina and the muscle 
nuclei). Centrifugal fibres of the corona radiata must also termi- 
nate in them, as in other muscle nuclei, but we possess no further 
anatomical knowledge concerning this point. A part of the anterior 
central convolution, immediately above the speech centres, seems to 
be connected with the origin of the inferior facial nerve. Injury to 
a spot in front of and above the one just mentioned, in front of the 
centre for the upper limb, gives rise to crossed ptosis. This region 
is accordingly connected with the nucleus of the motor oculi, at least 
with the nucleus for the levator palpebrse superioris of the other side. 



DISEASES OF THE NERVOUS SYSTEM. 25 

The external ocular muscles may be made to perform co-ordinated 
movements (chiefly toward the opposite side) from many parts of 
the cortex, but especially from the " visual sphere. " 

3. Course of the Sensory Nerves. 

The eye obtains its sensory nerves from the first and second 
branches of the trigeminus, the latter supplying only the lower lid. 
The nucleus of origin (probably the nucleus of termination) for the 
large sensory root of the fifth nerve extends from the middle of the 
aqueduct of Sylvius on the outside of the motor oculi and trochlearis 
nuclei to a point beyond the beginning of the central canal of the 
spinal cord. It is usually semilunar in shape on transverse section 
(vide scheme, Fig. 5, p. 16). It emerges from a groove in the crus 
cerebelli ad pontem. Hence we distinguish ascending and descend- 
ing root fibres. The latter contain an addition of crossed fibres from 
the cells of the lobus cseruleus. These pass along immediately be- 
neath the floor of the fourth ventricle to the raphe, decussate, are fre- 
quently intermingled, and there bend into the common trunk. The 
descending fibres likewise possess an origin from the raphe itself; 
these fibres decussate, and, according to Meynert, are derived from 
the cerebral peduncle. The nucleus of origin at the level of the 
point of exit of the nerve consists of a clump of gelatinous matter, 
similar to that in the posterior horn of the spinal cord; into this pass 
fibres from the cerebellum. The larger number of trigeminus 
fibres are ascending (Wernicke). If we take into consideration the 
direction of conduction, which is the decisive element, then the or- 
dinary terminology is incorrect. The " descending" fibres conduct 
upward, the "ascending" fibres conduct downward toward the 
spinal cord. 

The entire sensory portion of the trigeminus enters the Gasserian 
ganglion, from which the three branches of the nerve arise. The 
first and smallest branch runs forward, at first adherent to the outer 
and upper walls of the sinus cavernosus, and passes through the su- 
perior orbital fissure into the orbit. It sends the lachrymal nerve to 
the conjunctiva and the integument of the outer angle of the eye, 
the frontal nerve (supratrochlear and supraorbital) to the upper lid 



26 THE EYE IN RELATION TO DISEASE. 

and forehead, and the naso-ciliary nerve which passes with the abdu- 
cens through the origin of the external rectus. The branches of 
the last-named nerve are the ethmoidal nerve — which passes through 
the anterior ethmoidal foramen to the cranial cavity and then 
through the lamina cribrosa to the nasal cavity, and supplies the 
integument of the ala nasi below the nasal bone — and the infra- 
trochlear nerve which supplies the root of the nose, the upper lid, 
lachrymal sac, caruncula, and inner half of the conjunctiva. The 
lower lid obtains its sensory fibres from the second branch of the 
trigeminus, which passes through the foramen rotundum, then 
through the ptery go -palatine fossa, the inferior orbital fissure, the 
floor of the orbit, and the infra-orbital canal. The nerves which 
emerge from the latter beneath the middle of the inferior rim of the 
orbit, diverge in the shape of a fan and form the pes anserinus 
minor. The motor root of the trigeminus arises in front of the 
facial nucleus, passes between the anterior transverse fibres of the 
pons, and does not form part of the Gasserian ganglion but enters en- 
tirely into the third branch of the trigeminus; it has nothing to do 
with the eye. 

The destination of the axis cylinders of the ganglion cells of the 
trigeminus nucleus is unknown. It is probable that part, at least, 
pass to muscle nuclei in the brain and cord, and that in great part, 
together with the sensory track of the entire body, they pass to the 
opposite optic thalamus, where the received impressions are meta- 
morphosed by ganglion cells and conveyed mainly to the cortex of 
the parietal lobe, but undoubtedly also to other regions (cerebellum). 

The motor, sensory, and sympathetic nerve fibres for the interior 
of the eye and the cornea — with the exception of those which pass 
along the optic nerve itself and the central vessels of the retina — pass 
through the ciliary ganglion before entering the eye. This is situ- 
ated in the posterior part of the orbit between the external rectus and 
the optic nerve, and is about 3 mm. in diameter. It receives pos- 
teriorly three roots (which exhibit manifold variations in individual 
cases) ; anteriorly it sends the ciliary nerves to the eye. 

The motor root is derived from that branch of the motor oculi 
which passes to the inferior oblique (short root), the sensory root 



DISEASES OF THE NERVOUS SYSTEM. 27 

from the naso-ciliary nerve after its passage through the origin of 
the external rectus (long root) ; the sympathetic root is derived from 
the carotid plexus in the cavernous sinus and passes through the su- 
perior orbital fissure either to the ganglion itself or to its sensory- 
root. From the ciliary ganglion are derived the long and short 
ciliar}" nerves to the choroid, ciliary body, and iris, and particularly 
to the internal muscles of the eye, the ciliary muscle, sphincter and 
dilator of the pupil. 

The sensory nerves of the cornea (probably also of the sclera) pass 
along the path of the ciliary nerves. But the sensory tract of the 
cornea is not sharply defined from the tract of the conjunctiva, which 
is supplied by twigs from the first branch of the trigeminus (Bou- 
cheron, Compt. Rend, de la Soc. de Biologie, 1809). 

The origin of the motor root of the ciliary ganglion from the 
motor-oculi branch to the inferior oblique makes it possible that the 
latter muscle, together with the sphincter of the pupil and accommo- 
dation, should alone be paralyzed if a peripheral (orbital) lesion 
affects this branch exclusively. 

B. Disorders in the Domain of the Ocular Nerves and 
their Central Origin. 

Here the chief importance attaches to the optic nerve and to those 
parts of the brain which are connected with its origin ; next to the 
nerves of the muscles, the sympathetic and the sensory nerves. We 
must distinguish : a, peripheral disorders, extending to the origin or 
termination in the brain; 6, intermediate, i.e., nuclear or gan- 
glionic disorders, when the ganglia of origin are attacked ; and c, 
central disorders proper, whose causes are located more centrally in 
the brain. 

1. Optic Nerve. 

Affections of the optic nerve and its centre of origin produce 
visual disorders in the proper sense of the term. The peripheral dis- 
orders are located in the eye, in the optic nerve, chiasm, and trac- 
tus; the ganglionic, in the three primary optic ganglia; the central, 
in Gratiolet's optic radiations and the occipital cortex, and also, so 



28 THE EYE IN RELATION TO DISEASE. 

far as visual impressions in the brain can be traced, in the systems 
of associative fibres of the occipital cortex and in the other parts of 
the cerebral cortex which are connected therewith. 

A. Peripheral Visual Disorders. 

The peripheral visual disorders really belong to the field of spe- 
cial ophthalmology, and will be discussed here as briefly as possible. 

1. Intra-ocular Visual Disorders. — These may consist of 
opacity of the refracting media and irregular shape (astigmatism) of 
the refracting surfaces of the cornea and lens, or of improper focus- 
ing on the retina. An important difference between these two forms 
is shown by the fact that, with equal vision, colored (red and blue) 
squares are recognized as such at a less distance when the media are 
opaque than when we have to deal simply with incorrect focusing 
of clear media (uncorrected errors of refraction and astigmatism). 
In both cases the visual field is normal. 

If the visual disorder is owing to changes in the choroid, retina, 
or optic nerve, the color sense is usually disturbed to a greater extent, 
especially as regards quality, at least when the retina and optic nerve 
are implicated to a notable degree. We can often demonstrate de- 
fects of the field of vision, either concentric or sector-shaped narrow- 
ing of the field, or single or more or less numerous scattered blind 
or amblyopic spots (scotomata). These are either seen as mist, 
smoke, etc. (positive scotoma, especially when the percipient parts 
of the retina, occasionally also the conducting fibres, are not entirely 
incapable of function), or they are only demonstrable on testing the 
field of vision (negative scotoma). Total removal or destruction of 
an eye also causes a corresponding negative scotoma. 

In diseases of the fundus oculi proper the disturbance of the color 
sense may be twofold. 

a. The same as that which appears in the normal individual 
when the illumination is diminished ; gradual narrowing of the vis- 
ible spectrum from both sides, weakness of color with bilaterally nar- 
rowed spectrum, because on the one hand red, orange, and yellow, on 
the other hand blue and violet can be distinguished less and less dis- 
tinctly), so that gradually the middle of the spectrum appears color- 



DISEASES OF THE NERVOUS SYSTEM. 29 

less and only a more refractive (cold) color called blue, and a less 
refractive (warm) color, usually called yellow, rarely red, can be dis- 
tinguished (green-blindness or two-color vision with bilaterally con- 
tracted spectrum). Finally, even these two colors can no longer be 
distinguished, and only the middle of the spectrum appears color- 
less (white to gray) (total color-blindness with bilaterally strongly 
contracted spectrum). This form of color disturbance is observed in 
diseases of the conducting apparatus, the optic nerve, and probably 
also the larger of nerve fibres in the retina, and is therefore best 
called "conduction color disturbance." In these cases it is found not 
infrequently that, although there is color-blindness in ordinary day- 
light, the colors are still recognized correctly (Knies, " Heidelberger 
Berichte," 1889, p. 7) in a very intense light (sunlight). 

h. The second form of color disturbance is very closely allied to 
the condition of one with normal color sense, who looks through a 
yellow glass, until the yellow sensation is no longer subjectively 
noticeable, ^.e., until yellow and white appear almost identical. 
It is well known that looking through a yellow glass at first causes 
a very decided feeling of being dazzled, although objectively less 
light enters the eye, inasmuch as the violet rays are removed.^ 
Apart from the already mentioned confusion of yellow and white^ 
red and green are recognized very well (appearing more vivid) , blue 
to a less extent (with a dark yellow glass it is seen as green ; but 
then the spectrum is also noticeably contracted at the red end). 
Violet appears black, carmine red {i.e.^ red and violet) appears dull 
red. An exactly similar disturbance of color is found in choroidal 
affections with implication of the external layers of the retina, de~ 
tachment of the retina, etc. The similarity becomes still greater 
when, as happens not infrequently, though temporarily, in acute 
cases, objects are seen colored (usually yellow, more rarely green) , 



^ In former years marksmen in shooting for prizes not infrequently used yel- 
low glasses in order to improve the sight. To me, who wear not fully correct- 
ing concave glasses, Snellen's test types appear, through a yellow glass, in some- 
what sharper outlines than before, evidently because the focus of the rays in 
yellow light falls a little farther back in the eye than in the case of mixed white 
daylight. The recommendation of santonin in diseases of the optic nerve prob- 
ably depended on this subjective increase of distinctness. 



30 THE EYE IN RELATION TO DISEASE. 

analogous to the yellow vision which occurs occasionally in jaundice. 
By the perimeter the boundaries of blue are found contracted to a 
greater extent than those of red and green. This is also the case in 
santonin poisoning. 

Evidently we have to deal here with molecular changes or abnor- 
mal processes of decomposition ^ in the percipient external retinal 
layers. Perhaps there is a local hsematogenous formation of bile 
pigment. The action of santonin may also be similar. The media 
are sometimes visibly colored yellow, for example, in detachment of 
the retina. 

If the color disturbance under a is attributed to the conductive 
apparatus, this second form may be aptly called " perceptive color 
disturbance." They may occasionally be associated with one 
another. As both color diseases often appear only in patches in the 
field of vision, very different fields of color vision are possible. 
Color scotomata of the second variety are the causes of the very 
striking fields of color vision with reversal or mutual intersection of 
the boundaries for the different colors. 

After these preliminary considerations certain often-mentioned, 
more or less peripheral visual disorders will be more easily under- 
stood. We refer to day and night blindness, retinal asthenopia, 
dazzling, anaesthesia and hypersethesia of the retina. In their de- 
scription we follow Leber (Graefe-Saemisch's "Handb. d. Augen- 
heilk.," V, p. 980 et seq. and p. 1,005 et seq.). All these visual 
disorders are very often the results or concomitants of constitutional 
diseases. 

We must assume that in the act of vision photochemic actions 
are produced in the external layers of the retina by the entrance of 
light. The products (decomposition products, carbonic acid, etc.) 
act injuriously and must be removed by the blood-vessels and lym- 
phatics, while restitution (albuminoids, oxygen, etc.) for the de- 
composed and used-up material is furnished by the arterial blood- 

^ Allied processes (fatty degeneration) in the epithelium of the conjunctiva 
must also be assumed in so-called xerosis conjunctivae, which is often associated 
with evident nutritive disturbances in the external retinal layers (night blind- 
ness, torpor retinae) . 



DISEASES OF THE NERVOUS SYSTEM. 31 

vessels. Under normal conditions consumption and supply must 
stand in a certain harmonious relation. In a like manner the con- 
duction in the optic nerve, by means of which analogous processes 
are induced in the ganglion cells of the brain, must be carried on 
normally. As in other localities, the accumulation of products of 
disintegration causes fatigue. 

The nutritive material for the outer layers of the retina is fur- 
nished bj^ the chorio-capillaris of the choroid. The products of dis- 
integration may pass in part into the vitreous, but are also partly 
removed from the eye through the lymphatics of the retina and optic 
nerve. This affords the possibility of their disturbing action on con- 
duction in the optic nerve. 

Retinal asthenopia is abnormally rapid exhaustion of the eye, 
similar to that found in weakness of accommodation or insufficiency 
of the internal recti, albeit the latter conditions are not present. There 
is also absence of conjunctival hyperaemia which may produce simi- 
lar symptoms. Retinal asthenopia is usually a symptom of a general 
ansemic-chlorotic or neurasthenic condition. It is the most striking 
symptom simply because the patients, on account of the inability to 
follow any occupation, feel the giving way of the eyes with special 
severity. Recovery will only result from appropriate general treat- 
ment which is often A^ery tedious. In severe cases the use of the 
eyes is directly painful (neuralgia bulbi). 

The symptom depends upon imperfect nutritive changes in gen- 
eral, upon insufficient restitution despite normal disassimilation. It 
is very difficult to determine how much is peripheral, how much 
central in character, because similar defective conditions of nutri- 
tion must also be present in the central organs. 

In retinal hyperaesthesia there is excessive sensitiveness of the 
eyes to ordinary daj^light, especially to higher degrees of illumina- 
tion, while the acuity of vision and the field of vision are normal 
when the illumination is lessened. It is very often a part of gener- 
ally increased irritability of the entire nervous system (irritable 
weakness) and similar symptoms also occur in inflammatory affec- 
tions of the eye, especially of the cornea and conjunctiva. We must 
assume that the photo-chemical action of light causes much more 



32 THE EYE IN RELATION TO DISEASE. 

considerable, perhaps also more deeply spreading, abnormal disinte- 
grations, whose products themselves act as irritants. 

Photophobia may be peripheral in character from causes local to 
the eye, or it may be the result of brain disease; for example, in men- 
ingitis, when the products of inflammation give rise to an irritative 
condition in the optic nerve or the cerebral cortex. The absence of 
the excessive sensitiveness to light results in the condition known as 
day blindness (nyctalopia) . This coincides with hypersesthesia of the 
retina so far as regards the visual disorder, viz. , impairment of vision 
with ordinary or bright illumination, improved or normal vision 
with lessened illumination. This is observed when, for any reason, 
an abnormal amount of light enters the eye (large coloboma of the 
iris, mydriasis), or in imperfect pigmentation of the fundus oculi 
(albinism and the like), and also in certain diseases of the retina 
(Arlt's retinitis nyctalopica) and the optic nerve (intoxication am- 
blj^opia). In all these cases the efficient factor appears to be the 
insufficient restitution of the material employed in the act of vision, 
this being sufficient only when the action of the light is diminished. 

Similar symptoms are found in those who have lived for a long 
time in the dark, for example, in dark dungeons. The diminished 
nutritive changes which have become habitual in those parts of the 
retina which are sensitive to light do not suffice in bright daylight. 

Y. Graefe originally applied the term retinal anaesthesia to a con- 
dition in which central vision was more or less impaired, and the 
field of vision, in particular, had undergone pronounced concentric 
narrowing. On pressing upon the insensitive parts of the retina the 
well-known phosphenes could generally (though not always) be pro- 
duced, and hence it was inferred that conduction was unimpaired. 

Foerster (" Heidelberg. Ber.," 1877, p. 162) has called attention to 
the fact that often the narrowing of the field of vision can only be 
demonstrated when the moving object is carried from the point of 
fixation toward the periphery, but not when it is carried in the 
opposite direction. 

The ophthalmoscopic appearances are normal even after the con- 
dition has lasted for years. The condition may appear and disap- 
pear suddenly. In the highest grades there is complete blindness 



DISEASES OF THE NERVOUS SYSTEM. 33 

with or without normal reaction of the pupils to light. Within the 
existing field the color sense may be normal. It may be dimin- 
ished, even to total color blindness, in the conductive form of dis- 
turbed color sense described on page 29. In rarer cases we find a 
disturbance of color which approaches more closely to the disturb- 
ance of sensation there described. Other "nervous" disorders are 
often present. 

Anaesthesia of the retina is often observed in children at the 
period of puberty and in nervous women. A special form is de- 
scribed as hysterical amblyopia and amaurosis. It may also be due 
to injury (traumatic hysteria). Both forms will again engage our 
attention. 

The location and cause of the disease are not at once evident. 
The retina, the conducting elements, and the central organs may be 
affected, and in different ways in different cases. Vasomotor disor- 
der is the most probable cause, although not in the distribution of 
the central artery of the retina. 

If the nutrition of the external laj'ers of the retina by the choroid, 
particularly by the chorio-capillaris, were imperfect (as in spasm of 
the ciliary arteries), the symptoms of pure retinal anaesthesia would 
result. The periphery of the retina would suffer most ; the macula, 
which is much more favorably situated as regards nutrition, might 
still perform its function in a tolerable degree. The result would be 
concentric narrowing of the field of vision with more or less intact 
central vision. The pigment epithelium would make it impossible 
to recognize the condition with the ophthalmoscope. Moderate 
pressure on the eye produces exactly similar phenomena, including 
the pressure-phosphenes. 

On the other hand, interference with the optic nerve, anywhere 
in the region of the optic foramen, also produces concentric narrow- 
ing of the field of vision, because the fibres of the macula are most 
protected in that locality. Here the color disturbance, which is 
characterisic of interference with conduction, would also be present, 
and this is one of the main symptoms of hysterical amblyopia. In- 
deed Leber (/. c, p. 985) found even material changes in the periph- 
eral bundles of the optic nerve in a so-called hysterical amblyopia 
o 



34 THE EYE IN RELATION TO DISEASE. 

without ophthalmoscopic findings. Even in this location of the 
affection the ophthalmoscope would show nothing in the retinal ves- 
sels, which only enter the optic nerve immediately behind the eye. 

While peripheral and central causes usually act together in the 
complex of symptoms hitherto discussed, so-called night blindness 
(torpor retinse, hemeralopia) must be attributed in the main to a 
peripheral change in the outer layers of the retina, although the 
optic nerve may suffer secondarily. Vision is perfectly normal in a 
good light, but in twilight it fails disproportionately. The ophthal- 
moscope shows nothing abnormal save more or less hyperaemic signs 
in the fundus oculi. Adaptation to darkness is also impaired so 
that the eye suffering from night-blindness requires when the 
illumination is diminished, four to ten times the time required by a 
normal eye to attain the corresponding maximum of vision. In addi- 
tion the subjective light phenomena caused by pressure on the eye 
(pressure phosphenes) are decidedly diminished, and may even be 
entirely absent. In pronounced cases the disorder of color percep- 
tion described on p. 29 is also present, and is characterized particu- 
larly by diminished recognition of violet and blue.^ 

The acute forms occur after dazzling, associated with impaired 
nutrition ; for example, during the strict Lenten fasting in Russia, 
where at the same time the snow reflects a glaring sunlight ; in be- 
sieged fortresses, on shipboard, during scurvy or other severe general 
disturbances, after infectious diseases, etc. In these cases the fun- 
dus oculi is found normal. At the same time a characteristic xerosis 
of the conjunctiva is often present. It is to be assumed that deeply 
spreading changes in the external layers of the retina impair the per- 
ception of light quantitatively and qualitatively. This is analogous 
to the fatty degeneration of the epithelium in conjunctival xerosis 
within the inter- palpebral fissure, and which results from abnormal 
irritants (reflection from the snow, etc.) combined with insufficient 
nourishment. 

In other cases night-blindness is a sign of more or less acute cho- 

^ In night-blindness the violet sensation is very often diminished at the pe- 
riphery. This will escape discovery if, as ordinarily happens, only the tests for 
red, green, and blue are made. 



DISEASES OF THE NERVOUS SYSTEM. 35 

roidal diseases— perhaps preferably chorio-retinitides and retinal affec- 
tions with decided implication of the external layers of the retina 
and intact conduction. Corresponding ophthalmoscopic appearances 
are then found. In such cases the color disturbance is also more 
pronounced. Its analogy with vision through a yeUow glass is still 
further increased by the fact that in very acute cases subjective col- 
ored sight occurs (usually yellow vision, more rarely green vision). 

I may here mention that every healthy individual by looking through a yel- 
low glass, can not only imitate the corresponding disturbance of color, but also 
exhibits the symptoms of night-blindness, viz., considerable slowing of adapta- 
tion and marked impairment of vision in the dark. 

Day-blindness also occurs as a congenital affection without find- 
ings. It is best known as a symptom of a definite form of chorio- 
retinitis, which is called retinitis pigmentosa. In this disease the 
degeneration of the pigment epithelium, the atrophy of the choroid and 
of the outer layers of the retina in the later stages are also visible with 
the ophthalmoscope. On account of the very chronic course a color 
disturbance is usually not demonstrable during the degeneration 
of the light-perceiving layers of the retina {vide the note on the pre- 
ceding page). In the places which still perform their function the 
color sense is normal, on account of the intact conduction. The 
marked impairment of vision in diminished illumination and in the 
dark alone shows the beginning degeneration of the percipient layers 
of the retina. 

When there is simply dazzling of an otherwise healthy eye, i.e.^ 
excessive photo-chemical decomposition without corresponding resti- 
tution, the subjective symptoms are always the same as if less and 
less light were entering the eye, i.e., obscuration of the field of vision 
extending to complete blindness (for example in snow-blindness prop- 
er). The normal condition is soon restored after rest and darkness. 
On the other hand, it is easily understood that, in individual cases, 
dazzling may give rise to the opposite condition so that hj^persesthesia 
as well as anaesthesia of the retina, day-blindness as well as night- 
blindness, may be brought about. We must not overlook the action 
of heat on the pigmented parts of the fundus, which may be inten- 
sified into the burning in of a solar image into the pigment epithe- 



36 THE EYE IN RELATION TO DISEASE. 

lium (in observing an eclipse of the sun without a smoked glass). 
The nutritive disturbances in the choroid as the result of radiating 
heat must also be regarded as the probable cause of the development 
of cataract in glass-blowers. 

To sum up briefly : asthenopia of the retina is its easy exhaus- 
tion ; hypersesthesia of the retina is excessive irritability of the entire 
peripheral and central visual apparatus, although certain parts may 
be implicated to a more marked degree. The essential element of 
day-blindness, which is, in the main, peripheral, is imperfect restitu- 
tion of the material used up in the process of vision. In retinal 
anaesthesia there is diminished and often qualitatively changed 
action of light upon the percipient retinal elements, or diminished 
conducting power of the optic nerve, or both ; in night blindness and 
torpor of the retina there is, in the main, only the former condition. 
All of these terms are not very happily chosen. There are also con- 
siderable differences of opinion with regard to details, but we cannot 
enter upon them here (compare, for example, Treitel, Arch. f. OpMh.^ 
XXXIII, 1 and 2; XXXV, 1; XXXYI, 3, and XXXVII, 2). To 
mention two technical expressions which are often used, initial stim- 
ulus (Reizschwelle) means the faintest objective light stimulus which 
can be perceived, and the differential stimulus (Unterschiedsschwelle) 
is the amount of difference between two impressions of light which 
can just be distinguished as possessing different degrees of brightness. 

Although the visual disorders under consideration are, in great 
part, of a peripheral character, we have discussed them somewhat in 
detail because we will again come in contact with them under the 
heading of the most varied general diseases. It is also easily under- 
stood that to a certain degree there may be combinations of the 
forms mentioned, for example, of retinal anaesthesia with hyper- 
sesthesia (photophobia). 

On account of the specific energy of the nerves of special sense, 
neither the retina nor optic nerve can be the seat of real pain. But 
pains may result from the entrance of light on account of the impli- 
cation of other parts of the eye or of the central organs. 

2. Diseases of the Optic Nerve. — If conduction is entirely 
interrupted in one optic nerve, there is unilateral blindness. The 



DISEASES OF THE NERVOUS SYSTEM. 37 

pupils of both eyes will not react on the entrance of light into the 
blind eye, but both react to an equal degree on the entrance of light 
into the healthy eye (consensual pupillary reaction), unless there are 
mechanical hindrances, such as synechiae. Hence, in unilateral 
blindness whose cause is situated in the optic nerve (or in the 
retina), the pupils of both eyes are equal in width, unless complica- 
tions render this impossible. 

If an optic nerve is only partly destroyed, there is loss of function 
of all those parts of the retina to which fibres are sent by the de- 
stroyed section. Hence, according to the site of the lesion, there 
will be concentric or sector-shaped narrowing of the field of vision, 
central or peripheral scotoma, or various combinations {vide Fig. 3, 
p. 4), 

If the optic-nerve fibres degenerate slowly, as often happens, the 
impairment of vision for the corresponding parts of the retina occurs 
in exactly the same way as if these received a much more feeble 
illumination (amblyopic spots in a monocular field of vision). The 
scotomata are usually negatiA'e. 

At the same time there occurs, as a very characteristic feature, the 
color disturbance which we have called conduction disorders of color 
and have described on page 29. It is only absent in very chronic 
cases. The field of vision when taken with the perimeter shows nar- 
rowing of the boundaries of the colors, especially of green, red, and 
violet; subsequently these disappear completely, until finally even 
blue and yellow can no longer be distinguished. If the color boun- 
daries, as compared with the boundaries of the field of vision in gen- 
eral, are disproportionately narrowed, this indicates a rapidly pro- 
gressing process. If the narrowing for white and for colors is 
approximately uniform the process is slowly progressive or station- 
ary, although there are frequent exceptions to this rule. In partial 
disease of the optic nerve the color disturbance is confined to 
the corresponding part of the visual field. If the point of fixation 
or its immediate vicinity is not affected the subjective disturbance 
will be very slight, and the physician may readily overlook it, unless 
direct search is made for "peripheral color scotomata." 

Despite the impairment of vision a sort of day-blindness or hyper- 



38 THE EYE IN RELATION TO DISEASE. 

sesthesia to light in the amblyopic spots may be present, and is 
shown by improved vision with poorer illumination. This is espe- 
cially true in inflammatory processes in the connective tissue of the 
optic nerve, for example, in the central scotoma due to central (axial) 
neuritis in so-called intoxication amblyopia (day-blindness, nyc- 
talopia) . 

Sooner or later (at the latest, in six weeks) the ophthalmoscope 
will reveal corresponding findings, when there are material changes 
in the nerve fibres, viz., partial or total atrophy of the optic nerve. 
This will only be wanting when the nerve fibres themselves remain 
intact despite the interference with or even abolition of conduction. 

3. Disorders of the Chias^n. — Complete destruction or frontal 
division of the chiasm results in bilateral total blindness with aboli- 
tion of the pupillary reaction to light, because all the optic-nerve 
fibres are divided. But if the chiasm is divided in a vertical direction 
from before backward, both external halves of the retinae and therefore 
both internal halves of the fields of vision remain intact. Hence 
there is bilateral temporal hemianopsia. This was present in Weir 
Mitchell's case mentioned on page 6. The hemianopsia was not 
pure because it was not due to a clean cut exactly in the median line 
but to a progressive, destructive process (aneurism) which also caused 
degeneration of adjacent fibres. 

The visual disorders will vary according to the part of the chiasm 
which is destroyed, inasmuch as sometimes the crossed, sometimes 
the uncrossed, bundles are more affected. The defects in the field of 
vision are almost always bilateral and often more or less homony- 
mous, i.e., they occur in similar positions on both sides : to the right, 
above, below, etc. 

If the lesion is situated in the anterior or posterior angle of the 
chiasm, the crossed bundles are usually mostly affected and more or 
less complete bilateral, temporal hemianopsia, i.e., a bilateral loss of 
the outer halves of the fields of vision, may be the result. A quite 
considerable number of such cases have already been published. 
Hemia,nopsia is rare in diseases of the chiasm and then is only 
sharply defined for a time, because the affection is rarely situated 
exactly in the median line and affects both sides uniformly. Usu- 



DISEASES OF THE NERVOUS SYSTEM. 



39 



ally we have to deal with progressive processes, turaors, syphilitic 
and tubercular proliferations, etc. The anatomical conditions in the 
chiasm explain the fact that hemianopic symmetrical defects in both 
nasal halves of the fields of vision are so rare. A single lesion 
could produce them only under very peculiar conditions, but they 
might result from bilateral symmetrical lesions. 

Foerster (/. c, p. 113) even denies the occurrence of binasal 
hemianopsia, but since then a few cases have been reported, for 
example, by Herschel {Jahr. f. Aug., 1883, p. 111). But if we as- 
sume that the course of the 
fibres in the optic nerve is like 
that claimed by Wernicke 
and Schmidt-Rimpler {vide 
p. 4) , and illustrated in Fig. 
7 — this course appears to be 
the exception, not the rule — 
then a single lesion in the 
anterior angle of the chiasm, 
between the two optic nerves, 
may give rise to a condition 
somewhat like binasal hemi- 
anopsia. 

From the blind parts of 
the field of vision the light 
reaction of both pupils cannot 
be obtained ; from those parts 

of the field which are still present — unless there are complications — 
both irides are uniformly innervated. The pupillary reaction to con- 
vergence, accommodation, and cutaneous irritation is present and 
equal on both sides. 

As we generally have to deal with progressive processes other 
cerebral nerves in the vicinity of the chiasm are very often attacked, 
for example the olfactory, the motor nerves of the eye, the trigemi- 
nus, etc. Not infrequently they are attacked in succession in a typi- 
cal manner. 

It is preferable not to employ the term hemianopsia for such dis- 




FiG. 7.— Schematic Diagram of the Chiasm, after 
Wernicke, but including the course of the macular 
fibres (black) ; the bundles corresponding to the right 
half of the field of vision are shaded. L, Left; E, 
right eye; GC, Gudden's commissure. 



40 THE EYE IN RELATION TO DISEASE. 

orders of the field of vision, as the half -blindness is almost always 
onl}^ an approximate one. It would be better to speak of symmetri- 
cal defects. Hemianopsia and half-blindness would then be em- 
ployed only for bilateral homonymous forms (right-sided or left- 
sided). In incomplete hemianopsia we would speak of homony- 
mous defects in contrast to symmetrical ones. 

4. Disorders of the Optic Tract. — In the optic tract at a little 
distance from the chiasm, the fibres from both sides are intermin- 
gled in such a way that destruction of any part causes homonymous 
defects in the visual fields of both eyes. Slight differences in the 
position and extent of the defects do occur, because the combination 
of the fibres from both sides is not yet completely uniform in the 
beginning of the optic-nerve tract. The very fact that the fibres 
from both optic nerves, or at least the majority of them, do not run 
in bundles, might give rise to the mistaken opinion that an ascend- 
ing degeneration of the optic nerve stops at the chiasm. On account 
of the intimate commingling of fibres, atrophies of considerable extent 
cannot be demonstrated, but there is merely more or less uniform 
diminution in the volume of the entire tract (or both tracts) . Even 
this may be compensated in a measure by a corresponding increase 
in the amount of interstitial tissue. 

Destruction of an entire tract causes typical homonymous 
hemianopsia, the retinal halves on the same side or the halves of the 
visual fields on the opposite side being lost. At the same time there 
is loss of the light reflex of the pupils, which could be excited from 
the blind halves of the retinae. There is hemianopic pupillary reac- 
tion (also called Wernicke's symptom), i.e., the light reaction of both 
pupils is intact on illuniination of both halves of the retinae which 
are sensitive to light, but does not follow when light falls upon the 
insensitive halves of the retinae. " Hemianopic light rigidity" is a 
better term for this condition. 

Hemianopic light rigidity of the pupil is an extremely rare 
symptom, because isolated disease of one tract or degeneration con- 
fined to one optic tract (this is most apt to result from a hemor- 
rhage) is equally rare. Its occurrence has been doubted by a num- 
ber of writers, but a few typical cases have again been published 



DISEASES OF THE NERVOUS SYSTEM. 41 

recently, so that the possibility and hence the diagnostic value of this 
symptom have been assmned {vide Martins' Charite Annalen, 
XIII, 1888; Seguin^Journ. of New. and Ment. Dis., Nov., 1887). 

In incomplete destruction of one optic tract the hemianopsia is 
also incomplete and the defects are more or less accurately homony- 
mous. The defects are probably so much more distinctly homony- 
mous the nearer the lesion is situated to the primary optic ganglia. 
This cannot be proven by examples, however, on account of the 
small number of diseases of the tractus which have been thoroughly 
observed clinically and anatomically. 

When conduction in the chiasm and optic tract is merely im- 
peded but not abolished, the same symptoms appear with regard to 
the recognition of colors as in interference with conduction in the 
optic nerve, except that they are more or less accurately homony- 
mous in both eyes. 

It is noteworthy that, in very pronounced interference with con- 
duction in one tract, the hemianopic or homonymous defect may be 
seen as a positive scotoma, as a mist or smoke. This was true, for 
example, of Spierer's case {Mon. f. Aug., 1891, p. 218), in which a 
hemorrhage probably took place into one tract as the result of fright 
following an earthquake. In such cases a positive scotoma is prog- 
nostically favorable, because complete interference with conduction 
cannot have occurred. As a rule positive scotomata are observed 
only in diseases of the outer layers of the retina, so long as the latter 
are not entirely destroyed. They also occur occasionally in dis- 
eases of the optic nerve. I have observed this a number of times in 
so-called toxic amblyopia. 

When actual destruction of nerve fibres takes place in the pe- 
ripheral visual disorders hitherto discussed, total or partial atrophy 
of the optic nerve becomes visible sooner or later with the ophthal- 
moscope. Not infrequent^, however, there is a certain lack of har- 
mony — sometimes quite pronounced — between the visible findings in 
the optic nerve and the disturbance of vision. In the first place, a 
certain time elapses before the abolition of conduction in the deeper 
parts of the nerve, the chiasm and the tract, becomes noticeable at 
the entrance of the optic nerves. In addition, the visual disturb- 



42 THE EYE IN RELATION TO DISEASE. 

ance is relatively marked and the ophthalmoscopic appearances are 
relatively slight when there is only interference with conduction 
but the optic nerve fibres are still intact, as, for example, in so-called 
toxic amblyopia, in the optic-nerve affections of multiple sclerosis, 
etc. On the other hand, the atrophic discoloration of the papilla 
may be very pronounced, and the disturbance of vision may be very 
slight or absent. The latter condition is observed particularly after 
the recovery from optic neuritis. If the disturbance of vision is 
located in the eye or at the entrance of the optic nerve the vessels of 
the retina are usually more or less narrowed. If it is located behind 
the entrance of the central vessels into the optic-nerve, the calibre of 
the retinal vessels may be normal for a long time or permanently, 
even if there is complete blindness. 

In symmetrical or homonymous defects of the field of vision 
from partial disease of the chiasm and tract, the atrophy visible with 
the ophthalmoscope is often confined to the corresponding sector of 
the papilla, in the same way that, in axial degeneration of the optic 
nerve, the atrophic discoloration is often confined to the outer half 
of the nerve disc. 

If there is simply interference with or abolition of conduction with- 
out destruction of the nerve fibres, and the cause is located behind the 
entrance of the central vessels into the nerve, all ophthalmoscopic 
abnormalities may be permanently absent despite long duration of 
the process and serious disturbance of vision. Other reasons must 
then determine the diagnosis of a peripheral affection (for example, 
its unilateral character, because unilateral disturbances of vision 
cannot be located in or beyond the chiasm) . This is also true of 
typical hysterical disorder of vision, unilateral anaesthesia of the 
retina {vide p. 33), which will be considered in detail at a later 
period. 

It is a common feature of all peripheral visual disorders that no 
light reaction of the pupils can be obtained from those parts of the 
monocular or binocular field of vision which are insensitive to light, 
although both pupils react uniformly to the entrance of light upon 
sensitive parts. This is demonstrated most easily in homonymous 
hemianopsia from loss of function of an entire optic tract, for the 



DISEASES OF THE NERVOUS SYSTEM. 43 

recognition of which the hemianopic light rigidity of the pupil is 
decisive. 

B. Intermediate Visual Disorders. 

In the so-called primary optic ganglia (anterior corpora quadri- 
gemina, pulvinar of the optic thalamus and external geniculate 
body), the visual fibres for the first time enter into relations with 
other systems of fibres. 

Id the primary optic ganglia, as in all other ganglia, are found : 1, a fine 
network of the entering nerve fibres ; 2, a fine network of the protoplasmic 
processes of the ganglion cells ; 3, ganglion cells which, in part, send out axis- 
cylinder processes, in part do not ; 4, nerve fibres which may simply pass 
through ; 5. the neuroglia and the vessels. 

In any ganglion there may be either an increase or a diminution of the nerve 
fibres, because more axis cylinders may emerge than are lost in the fibrillary 
network; and, on the contrary, the opposite condition may hold good. Fibres 
of different origins usually meet in one ganglion, and the efi'erent axis-cylinder 
processes have different destinations ; but certain lines of direction usually pre- 
dominate. Fibres may also run in both directions between two ganglia. 

Experiments on animals with regard to the primary optic ganglia may only 
be utilized in man with great caution, because their function differs markedly 
in different classes of animals. 

Positively convincing cases of lesions of the primary optic ganglia 
are very few if we regard onl}^ their clinical symptoms. It is known 
that destruction of one pulvinar causes crossed hemianopsia, and 
that the anterior corpora quadrigemiiia may be destroyed without 
notable disturbance of vision. 

Gowers observed choked disc, but without complete blindness, 
after considerable destruction of the anterior corpora quadrigemina. 

Nieden observed complete destruction of the corpora quadrigem- 
ina without pronounced disorders of vision. The slighter the 
symptoms, the purer and more important is the case and the experi- 
ment. Destruction of the parts with almost intact vision is convinc- 
ing. It is evident that the anterior corpora quadrigemina have 
nothing to do with conscious vision. 

According to Nothnagel there are found, in disease of the cor- 
pora quadrigemina, cerebellar ataxia and disorder of the ocular 
movements, but not of the pupillary movements and of vision. 
According to Eisenlohr (Muench. med. Wochen., 20, p. 90), on the 



44 THE EYE IN RELATION TO DISEASE. 

other hand, the movements of the pupils are controlled by the ante- 
rior corpora quadrigemina. After a shot from a revolver the bullet 
was found encapsulated in the right anterior corpus quadrigeminum ; 
in addition to the other symptoms, the right pupil was nearty twice 
as large as the left, and the associated movements of the eyes up- 
ward and downward were interfered with. 

Knoll found the pupillary reaction intact after experimental de- 
struction of the corpora quadrigemina. 

According to Adamuek the corpora quadrigemina are the centre 
for associated movements of the eyes. The right anterior corpus 
controls the movements toward the right, the left corpus those 
toward the left. Irritation in the median line between the two 
causes movement upward with marked mydriasis ; irritation of the 
most posterior parts causes pronounced convergence downward and 
myosis. 

According to Bechterew the anterior corpora quadrigemina per- 
ceive light, and exhibit relations to sensibility, to blood pressure, and 
to the vasomotor nerves. He denies their connection with pupillary 
reflexes. 

Knoll obtained dilatation of the pupils on feeble irritation of one 
anterior corpus quadrigeminum ; Ferrier saw the same results in addi- 
tion to dilatation of the palpebral fissure and rotation of the head 
and eye toward the opposite side. 

In Ziehrer's experiments (Arch. f. Psych., XXI, 3) every deep 
irritation of the anterior corpora gave rise to motor phenomena: 
acceleration of respiration, manifestation of anger, violent move- 
ments, rapid running movements, and often nystagmus and dilata- 
tion of the pupil on the same side. Traction on the brachia of the 
corpora quadrigemina gave rise to rapid running movements, but 
division of the brachia caused no symptoms. Strong irritation of 
the posterior corpora quadrigemina caused tetanic rigidity which 
outlasted the irritation ; the eye was often closed by an almost tonic 
spasm. The motor effects on the same side of the body predominated. 

In the main, all these experiments show the relations of the 
anteria corpora quadrigemina to the external ocular muscles, the 
nuclei of which are situated, in part, directly beneath them. These 



DISEASES OF THE NERVOUS SYSTEM. 45 

muscles control the associated movements. The fibres to the nucleus 
of the sphincter of the pupil very probably pass in close proximity. 
Relations to conscious vision in man are wanting or Yery slight. 
On the other hand there is a good deal in favor of the view that the 
anterior corpora quadrigemina convey to the occipital cortex the 
knowledge of involuntary ocular movements which follow upon 
light stimuli ; and these movements are either directed or inhibited 
by the occipital cortex. 

The pulvinar is simply the most posterior portion of the optic 
thalamus. The larger part of the fibres of the optic tract end in it, 
and terminate in a network. Its ganglion cells are known to send 
their axis-cylinder processes to the occipital cortex and degenerate 
after destruction of the latter (Monakow) . 

Hughlings Jackson {Lancet, 18T4) and Pflueger ("Ber. d. 
Berner Augenkl,," 18TS) observed crossed homonymous hemian- 
opsia in destruction of the pulvinar by hemorrhage. In a tumor of 
the thalamus and pulvinar Dercum {Jo urn. of Xerv. and Ment. 
Dis., 1890, No. 8) observed, in addition to hemianopsia, hemian- 
opic light rigidity of the pupil, although not in a perfectly pure 
form. Hence the visual fibres to the nucleus of the sphincter must 
either pass through the pulvinar or near by it. According to Schiff, 
Magendie, and others, irritation of one pulvinar has no influence on 
the ocular movements. Bechterew, on the other hand, often observed 
nystagmus or, rather, nystagmus-like, slow movements. It is to be 
remembered, however, that, in the experiment of exposing the thal- 
amus, the cerebral cortex was removed. The results in cases of 
tumor are less useful on account of the effect on neighboring parts. 
In one case of tumor Mills {Journ. of Xerv. and Ment. Dis., 1887, 
p. 707) observed drawing of the face toward the same side (crossed 
paralysis) and bilateral lagophthalmus (spasm of the levator?). 

The external geniculate body is an accumulation of ganglion 
ceUs within the large band of fibres of the optic tract, entering the 
pulvinar. Its cells send their axis cylinders to the occipital cortex 
(Huguenin, Meynert) in the region of the sulcus hippocampi. Only 
a part of the fibres terminates here in a network, another part passes 
alongside and through the external geniculate body to the pulvinar. 



46 THE EYE IN RELATION TO DISEASE. 

The only cases of isolated destruction of the external geniculate 
which are at all useful were observed by Tuerk {Zeitschr. d. G. d. 
Wien. Aerzte, XI, 1, quoted by Wilbrand (" Hemianopsia," p. 103). 
In both cases there was a cicatrix in and upon the ganglion of one 
side ; during life there was notable (sic I) disturbance of vision. 
Tuerk (Wilbrand, p. 104) also reports three cases in which numer- 
ous granular corpuscles were present in the tractus from the chiasm 
to the external geniculate body, while they were absent in the cor- 
pora quadrigemina and optic thalamus. 

After destruction of the optic nerves, tractus, and chiasm in the 
adult the ganglion cells of the primary optic ganglia remain intact, 
with the exception of a group in the anterior corpora quadrigemina. 
Only its outer layer of tractus fibres degenerates, and in this way the 
external geniculate body may appear to be notably flattened, although 
its ganglion cells are intact. Exceptions are very rare, and must be 
attributed to the fact that we have to deal either with an ascending 
degenerative process, or that the primary optic ganglia were first 
diseased, as is very apt to happen in tabes, multiple sclerosis, etc. 
In congenital blindness these ganglia are not developed; the same 
result is produced by experiments on newborn animals (Hadlich, 
Ctlhl. f. d. med. Wiss.^ 1880, p. 539). After destruction of the 
occipital cortex or its medullary fibres the ganglion cells of all three 
primary optic ganglia undergo degeneration (Monakow) . 

The pulvinar and external geniculate body are unquestionably of 
great importance in conscious vision. 

Inasmuch as clinical experience, pathological findings, and ex- 
periments furnish very incomplete data, we shall gain the best under- 
standing of the functions of the parts under consideration by careful 
study of the anatomical course of the fibres. Into the anterior corpora 
quadrigemina pass a certain number of fibres of the optic tract, and 
also a number of fibres from the so-called fillet. The latter conduct 
sensory fibres from the entire opposite half of the body to their ter- 
minal ganglia (corpora quadrigemina, but particularly the optic 
thalamus), not directly, but after a double interruption by ganglion 
cells, first in the spinal cord and then in the medulla oblongata. 
Sensory stimuli from the entire cutaneous surface of the opposite 



DISEASES OF THE NERVOUS SYSTEM. 47 

half of the body and light stimuli from the opposite half of the field 
of vision meet in the anterior corpora quadrigemina and optic thala- 
mus. Both anterior corpora quadrigemina are united by numerous 
fibres which decussate in the median line, hence the stimuli proba- 
bly act on both. 

We must probably also attribute to the pulvinar, in addition to the 
afferent fibres of the optic tract and the efferent corona radiata, as 
in the optic thalamus itself, a connection with the nucleus of the 
facial nerve (mimicry). 

The external geniculate body, in the main, receives optic-tract 
fibres and sends out medullary fibres to the occipital cortex. Hence 
it follows that, among other functions, the primary optic ganglia must 
convey or permit to pass through them involuntary reflexes from the 
organ of vision not alone to the ocular muscles but also to the mus- 
cles of the head and neck and of the entire body, first on one side, then 
on the other. The ganglia to which the fibres from the fillet pass 
preside over the involuntary reflexes from the cutaneous sensibility 
to the muscles of the eyes and face. 

What the primary optic ganglia are to the optic tract, the internal 
geniculate body appears to be to the acoustic nerve ; it presides over 
the involuntary reflexes from the organ of hearing to the muscles of 
the eyes, head, face, and then to the entire muscular system. 

This must be one of the functions of the primary cerebral gan- 
glion, in particular of the pulvinar and anterior corpora quadri- 
gemina, because it is hardly possible in any other locality. 

For example, if a strong sensory stimulus unexpectedly acts upon 
the dorsal surface of the left hand, then, apart from the local reflexes, 
the muscles of the neck will turn the head in that direction and the 
external ocular muscles will focus the eye upon the irritated spot. 
The same thing happens when a noise falls upon the ear, etc. If a 
violent sensory irritant acts upon the conjunctiva, then in addition 
to local reflexes (closure of the lids, etc.) there are others in the arm 
and hand, which are not even always useful, as, for example, rub- 
bing the eyes. Or if a light falls upon the retina, not alone are the 
head and eyes turned in its direction, but in the degree that the 
stimulus is intense and unexpected, motor effects follow in the 



48 THE EYE IN RELATION TO DISEASE. 

entire muscular system : a terrified start, outcries, running, etc. ^tf 
these movements are involuntary. They may be inhibited hf the 
higher centres and can also be replaced by others, but this is so much 
more difficult, the more intense, unexpected, and unusual the stimu- 
lus has been. 

It is still uncertain whether these reflexes are determinately 
acted upon by the ganglion cells in the primary ganglia of the brain 
or are simply conveyed through them. The latter is not improbable, 
because, as experiments show, the axis cylinde^;rs of the c^lls of these 
ganglia radiate almost exclusively into the corona radiata^nd to the 
cerebral cortex; they degenerate after destruction of the latter. 
The afferent sensory nerves are in their behavior similar to the pos- 
terior roots of the spinal nerves, which directly connect with all 
regions of the spinal cord by ascending and descending fibres. The 
visual fibres in an analogous way resolve into a network in all 
parts of the posterior horns (primary optic ganglia), and also pass 
into the anterior horns (nuclei of the ocular muscles) without demon- 
strable anastomoses (Koelliker, Muench. med. Woch., March 18th, 
1890). In the spinal cord we find also abundant decussations be- 
tween the anterior and posterior horns on both sides (in the anterior 
and posterior commissures), as we also find between the corpora 
quadrigemina and the nuclei of the ocular muscles. 

According to this view, the larger part of the fibres of the optic 
tract would be resolved, in the primary optic ganglia, into fine net- 
works amid which lie the ganglion cells. The latter send their axis 
cylinders central^ through the corona radiata to the cortex. To a 
less degree the fibres of the optic tract pass through the optic gan- 
glia and are only resolved into a network in the muscle nuclei, 
whose ganglion cells preside directly over the reflex involuntary 
movements. This is also true of those fibres of the fillet which are 
connected with the optic ganglia and the muscle nuclei. The fillet 
also sends its fibres into the neuropilemma of the optic thalamus, 
whence they are switched indirectly to the cerebral cortex as well as 
directly to the nuclei of the motor cerebral nerves. By means of the 
former the sensations are carried to consciousness, by means of the 
latter the direct involuntary reflexes are executed. 



' DISEASES OF THE NERVOUS SYSTEM. 49 

The peripheral stimuli which are constantly entering from every 
part of the body are distributed among the different muscle nuclei 
and thus effect a certain tension (tonus) of the entire muscular sys- 
tem. If stronger stimuli enter through any organ of special sense, 
then they will produce, in the nuclei, a condition of increased irrita- 
tion which corresponds to the point of entrance of the stimulus and 
diminishes as the distance from the latter increases (involuntary 
reflex). 

The more delicately graded and complicated are the muscular 
movements, the more numerous are the axis cylinders and the gan- 
glion cells which belong to them in comparison with the size of 
the muscle. The same thing is true of efferent sensory nerves and 
nerves of special sense in relation to the corresponding ganglia, 
the more finely graded the perceptive qualities are. If we assume 
that an afferent fibre, which is split up into a network of fine fibres, 
conducts a stimulus to a ganglion, then the ganglion cell which 
lies nearest to the point of entrance of the fibre in question will be 
irritated most intensely, the remoter ones less intensely, in a definite 
arithmetical or, more probably, geometrical proportion to the dis- 
tance. All stimulated ganglion cells conduct, with corresponding 
intensity, the stimulus to the muscle nucleus or to the cerebral cor- 
tex, and here again the same thing is true with regard to the gan- 
glion cells, viz., that they are all innervated, but that each one is 
stimulated with different intensity. Hence, if there is a considera- 
ble number of cells, great multiplicity of conscious or purely reflex 
movements is possible. 

This happens in the case of the eye. The number of visual fibres 
from the optic nerve and tractus, in proportion to the size of the sur- 
face of the retina, is enormously large when compared with other 
localities. This is also true of the nuclei of the ocular muscles in 
comparison with the size of the muscles innervated by them. Ac- 
cording to the location of the light impression on the retina, and 
according to its quality and quantity, the involuntary reflexes will 
be very finely graded. For this very reason it will possess a high 
degree of responsiveness to the character of the light stimulus, 

especially in regard to frequently recurring stimuli of the same or 
4 



50 THE EYE IN RELATION TO DISEASE. 

similar quality. Hence they will closely resemble intentional, vol- 
untary manifestations, and only when the stimulus is very unex- 
pected, unusual, and intense, will they possess the character of invol- 
untary reflexes and extend to the general muscular system of the 
body. 

An exceptional position is occupied by the movements of the 
internal smooth muscles of the eye, which are influenced by the 
will to a very slight degree or not at all. According to Mendel's 
latest investigations (Deutsch. med. Woch., 1889, 471), the fibres 
which convey the reflex reaction of the pupil to light run directly 
from the optic tract to the ganglion habenulse, which consequently 
effects the farther conduction to the muscle nucleus of the sphincter 
pupillae. He found in new-born cats, rabbits and dogs, from which 
the iris had been totally removed, that the corpora quadrigemina 
and external geniculate body remained intact, but that the ganglion 
habenulsB of the operated side was atrophic. According to Darsche- 
witsch the pupillary fibres of the optic nerve pass uncrossed to the 
ganglion habenulae of the same side (and to the pineal gland), at 
least in animals. Both ganglia habenul£e are freely connected with 
one another through the posterior commissure of the brain, and this 
readily explains the consensual reaction of the pupils. In accord- 
ance with these views Knoll found the movements of the pupils 
retained after destruction of the corpora quadrigemina. 

These observations are interesting on account of the relations of 
the ganglion habenulae to the pineal gland, which, as is well known, 
forms in part the rudiments of the so-called parietal eye. A certain 
support for this view is afforded by the relation of the pineal gland 
to the termination of the optic tract and to the nucleus of the motor 
oculi nerve. 

From these statements we can recognize how difficulties beset 
experimental investigation of the primary cerebral ganglia, how 
complicated the effects of irritation and destruction, and how coarse 
the experimental results must be. The individual elements of such 
a ganglion cannot be destroyed directly. We merely know that, 
after destruction of the occipital cortex or of the medullary fibres 
leading to it, the ganglion cells of the primary optic ganglia undergo 



DISEASES OF THE NERVOUS SYSTEM. 51 

degeneration. We assume that, after destruction of the optic tract, 
its terminal network of fibres in these ganglia and the fibres which 
merely pass through are also destroyed. This can only be demon- 
strated in part, however, by anatomical means. 

The principal function of the primary optic ganglia is undoubt- 
edly the transfer to the occipital cortex of the stimuli which have 
been conveyed to them from the periphery. This takes place 
through the axis cylinders of their ganglion cells. The fibres passing 
through the optic tract thus experience a very considerable increase 
in numbers, and this, as a matter of course, renders possible a much 
finer differentiation of the visual impressions received in the cere- 
bral cortex. 

It is probable that the union of the binocular visual impressions 
•of the corresponding halves of the field of vision into a single sensa- 
tion takes place in the primary optic ganglia. 

The anterior corpora quadrigemina are traversed by the fibres of 
the optic tract, which pass to the nuclei of the extrinsic ocular mus- 
cles. If they were destroyed separately, the involuntary reflex 
movements of these muscles would be abolished, but only in so far 
as they are aroused from the opposite half of the field of vision.^ 
But inasmuch as the impressions of light are conveyed by the other 
primary optic ganglia to the occipital cortex, corresponding or similar 
movements of the extrinsic ocular muscles (especially movement of 
the eyes toward the luminous object and fixation of the latter) will 
there be provoked as conscious movements. The loss of reflex 
motion could only be determined by accurate measurement of the 
interval between the stimulus and the resulting movement, which in 
this case is prolonged by a fraction of a second (on account of the 
longer distance). 

The pulvinar really constitutes only the posterior extremity of the 
optic thalamus. The fibres of the optic tract which pass to the 
former and the fibres of the fillet which pass to the latter probably 
form in great part a network in which lie ganglion cells whose axis 
cylinders enter the corona radiata. By means of these, visual impres- 
sions from the opposite half of the field of .vision are conveyed from 
1 Probably also from the opposise half of the entire body. 



52 THE EYE IN RELATION TO DISEASE. 

the pulvinar to the occipital cortex, and sensory impressions from 
the opposite half of the body are conveyed from the optic thalamus 
to the parietal cortex. Some of the fibres, however, merely pass 
through and terminate in the nuclei of the facial muscles. It is also 
certain that descending fibres of the optic tract pass down to the 
spinal cord, and subserve the involuntary reflexes of the general 
muscular system due to visual impressions from the opposite half of 
the field of vision. 

Inasmuch as auditory fibres also pass to the optic thalamus (to 
the internal geniculate body), and probably also fibres from the other 
sense organs, we must regard the thalamus and its appendages as an 
organ through which the tracts for the involuntary reflexes of all the 
senses pass to the facial muscles, perhaps also those of the higher 
senses to the general muscular system of the body. The relations of 
the thalamus to involuntary mimicry (Bechterew, Nothnagel) are 
thus easily understood. 

On the whole, the involuntary reflex movements which are pro- 
duced will be simple: rotation of the head and eyes toward the 
location of a sensory stimulus, distortion of the face (mimicry), de- 
fensive movements, inarticulate cries, movements of flight, perhaps 
manifestations of anger (preparing for resistance), starting of the 
entire body, when the irritant is very unexpected or intense, etc. 
The reflexes after sensory stimuli on the part of the eye (closure of 
the lids, rubbing, etc.) also probably pass through the thalamus. 

Inasmuch as the sensory fibres which pass to the individual 
nuclei (as far as the lower end of the spinal cord) come from all 
parts of the body, it will be impossible to cause degeneration of com- 
pact bundles of fibres from any sensory organ. 

The destruction of an optic thalamus, which naturally involves 
ganglion cells, network and fibres which pass through and near the 
organ, would, therefore, include abolition of the involuntary facial 
movements as reflexes from the opposite half of the body, ^^e., the 
mimetic movements in particular. The proof of this fact is difficult 
because, on account of the intact centrifugal connection with the 
muscle nuclei the same movements can still be produced voluntarily. 
Special attention must therefore be paid to this point, as Nothnagel 



DISEASES OF THE NERVOUS SYSTEM. 53 

has recently emphasized. But since, in destruction of the thalamus, 
a large number of ganglion cells are destroyed which send axis cylin- 
ders to the sensori-motor cortex, disturbances of sensation on the 
opposite side of the body, probably in the form of parsesthesise, might 
also be expected. Involuntary reflex movements of the trunk and 
limbs after cutaneous irritation of these parts are conveyed through 
the spinal cord and would remain unimpaired. 

The general remarks here made concerning the relation of the 
thalamus to the sensibility of the opposite half of the body are also 
true of the pulvinar and the visual impressions received from the 
opposite half of the field of vision. On account of the hemianopsia 
after destruction of the pulvinar, the loss of reflex movements from 
the side of the blind half of the field of vision will not appear as a 
special symptom, while their retention will so appear in central disor- 
ders of vision. Perhaps the fibres of the corona radiata which 
emerge from the anterior corpora quadrigemina and a part of those 
from the pulvinar serve solely to convey to the cerebral cortex a 
knowledge of the occurrence of the involuntary reflexes at the time 
of their production. If these do not occur on destruction of these 
structures, this function is also abolished without producing a notice- 
able symptom. Such an assumption would enable us to understand 
how reflex inhibition in general takes place. 

The external geniculate body is one of the principal terminations 
of the fibres of the optic tract, but in the cases reported (Tuerk, p. 
46) its lesion produced no notable disorder of vision. This is very 
surprising because the ganglion lies directly among the fibres of the 
tractus which are evidently concerned in vision, and it sends its 
axis cylinders to the visual cortex. I know only a single possibility 
in which the destruction of a large number of visual fibres of the 
tractus could take place without notable visual disturbance, viz., 
when macular fibres are affected, because these, as a rule, pass into 
both hemispheres. 

At first this view seems paradoxical. On more careful consider- 
ation, however, there is much in support of the opinion that it is the 
macular fibres which terminate, at least in great part, in the external 
geniculate body. The mid-position which they occupy among the 



54 THE EYE IN RELATION TO DISEASE. 

fibres to the pulvinar, which pass everywhere past and through the 
ganglion, would correspond to the position of the macular fibres in 
the optic tract, where they in all probabilit}'- also run centrally. A 
fraction of the macular fibres probably passes through the external 
, geniculate body to the pulvinar and subserves the involuntary reflexes ; 
the largest part, on the other hand, is resolved in this ganglion into a 
network of fibres. On account of the numerous ganglion cells which 
send their processes to the visual cortex, there is made possible a very 
fine differentiation of the sensory stimuli from the macula lutea, the 
site of most distinct vision in the retina. As regards the conscious 
voluntary motor manifestations called forth with the aid of the occip- 
ital cortex, preference would be given to the fibres coming from the 
macula lutea, but this would be true to a much less extent with re- 
gard to the involuntary reflexes. 

Tuerk {vide p. 46) reports three cases in which very numerous 
granular corpuscles were present in the optic tract from the chiasm 
to the external geniculate body, but were absent in the thalamus 
and corpora quadrigemina. In another case he found merely fatty 
degeneration of the medullary layer upon the external geniculate 
body, while the latter itself was intact. This would show that, as is 
true of the optic nerve, so also in the optic tract, there is a certain 
degree of antagonism, as regards disease, between the macular fibres 
and the peripheral fibres. 

I am well aware that the assumption that the macular fibres ter- 
minate in the external geniculate body is by no means proven, but 
it is worthy of discussion and is stimulating to special investigation 
which, unfortunately, I am unable to pursue at the present time. In 
destruction of the macular zone of the visual cortex the ganglion cells 
of the external geniculate body would necessarily be the principal 
site of degeneration. 

With regard to those fibres of the optic tract which pass to the 
nucleus of the sphincter pupillse, it is still doubtful whether they pass 
through the anterior corpora quadrigemina or the external geniculate 
body; they probably pass, close to both, directly to the ganglion ha- 
benulse (Mendel). If they alone were destroyed on one side, or at the 
same time with the anterior corpora quadrigemina (whose elimina- 



DISEASES OF THE NERVOUS SYSTEM. 55 

tion causes no visual disturbance), a peculiar symptom, which has not 
been observed hitherto, would develop, viz., hemianopic pupillary 
reaction without hemianopsia. Since this symptom must be spe- 
cially looked for, it may very readily escape observation. If the 
site of disease is suspected in the region of the corpora quadrigem- 
ina and optic thalamus, the hemianopic pupillary reaction without 
hemianopsia would be a very important focal symptom, which could 
only be produced in the narrow space betvv^een the termination of 
the optic tract and the nucleus of the sphincter on the same side. 
We will soon report a case of this kind, although it is not very 
sharply defined. 

In regard to the diagnosis of a lesion of the primary cerebral 
ganglia, the following points may be emphasized : 

Destruction of one pulvinar causes hemianopsia of the side oppo- 
site to the lesion ; the external geniculate body is usually destroyed 
at the same time. After a shorter or longer period bilateral hemi- 
atrophy of the optic nerve without diminution of the calibre of the 
vessels will become visible with the ophthalmoscope. At the same 
time there will be abolition of the involuntar}^ reflexes of the face 
and the entire muscular system (therefore, also, of mimetic move- 
ments) , but onlj^ in so far as they can be excited by visual impres- 
sions from the opposite half of the field of vision. As the latter is 
blind, this symptom will not be especially striking, but it must be 
referred to, because, in affections of the thalamus alone without im- 
plication of the pulvinar, abolition of the involuntary mimetic 
movements occurs without visual disturbance, ^he involuntary 
associated movements of the eyes (coarse binocular adjustment 
toward the site of the stimulus) as well as the reaction of the pupil 
to light (if the adjacent pupillary fibres are not also destroyed), 
could also be excited from the blind half of the field of vision. A 
special examination must be made with the aid of sudden and 
intense light stimuli. 

In destruction of one anterior corpus quadrigeminum the invol- 
untary conjugate and associated movements of the eyes would be 
abolished, but only in so far as they are excited by light stimuli 
from the opposite half of the field of vision. They might develop 



56 THE EYE IN RELATION TO DISEASE. 

after cutaneous stimuli, because the latter are conducted in the so- 
called posterior longitudinal bundles directly to the nuclei of the 
ocular muscles. 

As the involuntary associated movements of the eyes produce 
approximate binocular adjustment toward or away from the situa- 
tion of the stimulus, i.e., as they are adapted to an end, they may 
be replaced, inasmuch as vision itself is not disturbed, by the volun- 
tary performance of the same or similar movements, and may thus 
escape diagnosis. 

Hence the condition of the pupil is important because the fibres 
of the optic tract which pass to the nucleus of the sphincter pupillse 
pass close to the pulvinar as well as the anterior corpora quadrigem- 
ina, and because the reaction of the pupils to light cannot be influ- 
enced by the will. If these "pupillary fibres" are also destroyed, 
heminanopic pupillary reaction will develop, as in destruction of an 
entire optic tract ; hemianopsia is not, however, necessarily present 
and will be absent so long as the primary optic ganglia are in the 
main preserved. According to Mendel's investigations [1. c.) the 
same thing would happen if one ganglion habenulse were destroyed. 
Hence there is always sufficient reason for searching for the hemi- 
anopic pupillary reaction without the corresponding restriction of the 
field of vision, in suspected cases of disease in the region of the pri- 
mary optic ganglia. 

Isolated disease of one external geniculate body does not appear 
to be capable of diagnosis. That it does occur is shown by Tuerk's 
{I. c.) cases, in which notable disturbance of vision was absent. If 
my assumption that the macular fibres of one optic tract terminate in 
the external geniculate body is correct, then the destruction of the 
latter would give rise to paracentral homonymous amblyopic spots 
in both opposite halves of the fields of vision, while central vision 
might be entirely normal as in hemianopsia. With the ophthalmo- 
scope slight atrophic discoloration of both outer halves of the papillse 
might be expected after a certain lapse of time. If the lesion were 
situated on the left side the visual disturbance would be especially 
noticeable in reading, as in right homonymous hemianopsia. 

Such cases are not extremely rare. I have under treatment at the 



DISEASES OF THE NERVOUS SYSTEM. 57 

present time a man, aged sixty-four years, with symptoms of atheroma 
of the cerebral arteries, in whom a disturbance of vision suddenly 
developed five days ago and was especially noticeable in reading. 
On both sides V=f and the boundaries of the field of vision were 
normal; but reading was peculiarly slow and syllabic. The cause 
was found, not in a scotoma proper, but in a spot to the right of the 
point of fixation on each side, in which everything appeared much 
"duller." The reaction of the pupils to light was retained but was 
not very free. It was much more pronounced when the illumination 
came from the left side than when the light entered from the right. 
On the whole, the disturbance of sight was similar to that in so-called 
dyslexia (which see later). The ophthalmoscope showed on both 
sides a somewhat cloud}", grayish-red optic nerve, whose vessels were 
enclosed in white streaks, though only upon the papilla and its im- 
mediate vicinity. I can explain this case only as the result of a 
small hemorrhage either in the central bundles of the left optic tract 
or in the terminal ganglion of the central fibres of the tract, the ex- 
ternal geniculate body. In the former case the dimness of sight 
would be greater. The latter view appears to me the more probable 
one. As in Tuerk's cases, the expected post-mortem findings may 
consist of a cicatrix in the external geniculate body, and the reduc- 
tion of sight (V=|) might also have been regarded as not "notable," 
had not a special search for scotomata or amblyopic spots in the field 
of vision been made with the perimeter. A cortical disturbance of 
vision is excluded by the hemianopic diminution of the reaction of 
the pupils to light. 

C. Cortical Disordei^s of Vision. 

Under the term central disorders of vision we include those which 
are situated on the central aspect of the primary optic ganglia, ^.e., 
in Gratiolet's optic radiations and in the cortex of the occipital lobe. 
Those disorders which are located in associative and commissural 
fibres will be discussed later under the heading of transcortical dis- 
orders, for reasons which will soon be explained. 

The previous considerations and the anatomical course of the 
fibres of sight have proven conclusively that: 1, central disorders of 



58 THE EYE IN RELATION TO DISEASE. 

vision must be homonymous; 2, they furnish no ophthalmoscopic 
findings; 3, the invokmtary reflex movements due to light impres- 
sions remain intact even if the perception of light does not awaken 
consciousness. 

1. Experiment and clinical experience in man show that when the 
entire occipital cortex (visual sphere) is removed or destroyed, per- 
manent hemianopsia sets in, with loss of both opposite halves of the 
fields of vision. Degeneration takes place, as we have already said, 
in the ganglion cells of the pulvinar and external geniculate body 
and in a great part of those in the anterior corpora quadrigemina 
(^.e., with the exception of those which send centrifugal fibres into 
the optic tract). If both visual spheres are destroyed, there is total 
blindness (cortical blindness), with slight exception as seen by 
Foerster. Subjective sensations of light, such as photopsias and visual 
hallucinations, are no longer possible. In cortical hemianopsia they 
are possible only in the opposite half of the field of vision. Their 
presence proves that the occipital cortex is still capable of function. 

The visual disorder in hemianopsia is not infrequently regarded 
by the patient as unilateral and as affecting the eye in which the 
more important external (temporal) half of the field of vision is 
wanting. Right hemianopsia is regarded as a disturbance of sight 
in the right eye. Such mistakes are also made by physicians, and 
only a careful taking of the field of vision will prevent this error. 

In cortical hemianopsia the boundary of the field of vision may 
pass vertically through the point of fixation or may leave this free on 
both sides, or the intact fields of vision may have a vertical band in 
common (residual part of the field of vision) . The boundary may 
also run somewhat obliquely on both sides, and the defect is not even 
necessarily exactly uniform in both eyes. In short, there are subjec- 
tive differences within certain limits as in hemianopsia from periph- 
eral causes. The larger the number of cases which were carefully 
studied, clinically and anatomically, the more assured became the fact 
that in the distribution of the visual fibres there were no inconsider- 
able individual differences even in the occipital cortex, against which 
all theoretical considerations are useless. Hence it is impossible to 
construct a scheme which will hold in all cases for the finer localiza- 



DISEASES OF THE NERVOUS SYSTEM. 59 

tion in the occipital cortex. It is certain, however, that the macular 
region of the field of vision corresponds to the cuneus, and perhaps 
the first occipital convolution (Nothnagel's perceptive centre for visual 
impressions), and that, of the remainder of the occipital cortex (Xoth- 
nagel's memory centre for visual impressions), the anterior parts cor- 
respond to the inferior part of the opposite field of vision, the lateral 
parts to the outer, and the posterior parts to the upper part of the field. 

In partial destruction of one occipital cortex, accordingly, the 
visual disturbance will vary greatly according to the location. 
Destruction of the cuneus and its vicinity produces approximately 
the same effect, at least in man, as that of an entire occipital cortex, 
viz., homonymous hemianopsia, or at least marked hemiambl^'opia 
in the opposite half of the field of vision. This was the reason that 
N"othnagel applied the term perceptive centre for visual impressions 
to this part of the cortex. The part of the cerebral cortex correspond- 
ing to the macula lutea is evidently of much greater importance to 
conscious vision than the macula lutea itself, the destruction of which 
merely produces a central scotoma. If the lesion is situated in an- 
other part of the occipital cortex, the visual disturbance is much 
slighter, and is less noticeable the closer it is to the outer boundary 
of the visual sphere. According to the summary scheme furnished 
above, there would be present homonymous, more or less extensive 
(negative !) peripherally situated scotomata, or merely homonymous 
amblyopic spots, both of which produce practically no subjective 
symptoms and would not be discovered, on examination with the peri- 
meter, unless attention was speciallj^ directed to them. On the other 
hand, lesions of the cortical periphery may produce all sorts of dis- 
turbances in visual perceptions and memories and with the impres- 
sions of the other senses. These are mainl}' temporary, and, strictly 
speaking, included among the transcortical visual disorders which 
will be discussed later. 

Hence, it follows that only ISTothnagel's perceptive centre exhibits 
a tolerably pure optical character. The peripheral parts of the so- 
called visual sphere are of a mixed character sensorially, the optical 
portion predominating, but diminishing progressively toward the 
periphery. 



60 THE EYE IN RELATION TO DISEASE. 

According to theoretical considerations, partial destruction of one 
perceptive centre would give rise to a strictly homonymous loss of 
the field of vision (negative scotoma) of a corresponding size in the 
vicinity of the point of fixation of each eye. Wilbrand (" Die hemi- 
anopischen Gesichtsf eldf ormen, " Wiesbaden, 1890, p. 5) is also in- 
clined to assume a circumscribed hemorrhage into the perceptive 
centre of one side in a case of this kind under clinical observation. 
It might also be due to a small hemorrhage at the entrance of the 
tractus into the primary optic ganglia, perhaps even into the latter. 
Post-mortem examinations alone can decide such points. Hun's case 
{Amer. Journ. of Med. Sc, Jan., 188T) is the only one known to 
me. After an attack of apoplexy a man lost the left lower quadrants 
of the fields of vision and the peripheral parts of the left upper quad- 
rants. A lesion was found in the lower (?) half of the right cuneus. 
[For similar cases see Henschen.] 

Experiments on animals (the last ones by Obregia, Schaefer, Munk, 
etc.), with which clinical experience in man agrees, reveal another 
function of the occipital cortex. By stimulating the occipital cortex 
of one side with feeble currents conjugate movements of both eyes 
toward the opposite side are produced, in a somewhat upward direc- 
tion when the posterior part is irritated, in a downward direction 
when the anterior part is irritated. Hence the occipital cortex also 
exercises motor activity and, as we shall see later, brings about vol- 
untary movements of adjustment of both eyes upon an object which 
is appearing in the opposite half of the field of vision. Further de- 
tails will be furnished under the heading of the central disorders of 
the ocular muscles. 

Experiments on animals can be utilized for man only after the exercise of 
caution. The most reliable are those on monkeys, although even they present 
considerable anatomical differences from man. The different condition in many 
animals as regards decussation in the chiasm in itself enjoins caution, and still 
more the fact, for example, that birds are probably able to see after removal of 
the cerebral cortex, while the mammalia are not. In such cases parallels cannot 
be established even between larger parts of the brain which apparently are per- 
fectly homologous. 

Among clinical observations cases of softening are the most valuable, be- 
cause they are most sharply defined ; hemorrhages are less valuable, tumors least 
of all. Every rapidly or suddenly developing lesion gives rise, apart from the 
s> mptoms which correspond to its situation, to other more or less remote symp- 



DISEASES OF THE NERVOUS SYSTEM. 61 

toms, at first in the hemisphere of the same side, then in the opposite one (re- 
mote effects) . Only the symptoms which remain after a certain lapse of time 
are the real signs of the loss of tissue which can be utilized in localization. For 
example, if an embolism causes softening at the periphery of the occipital cor- 
tex, complete hemianopsia or even total cortical blindness may be present imme- 
diately afterward. In the latter event the opposite hemisphere first resumes its 
function and the cortical blindness passes into hemianopsia : then the latter is 
contracted into an homonymous scotoma, later still into an homonymous periph- 
eral amblyopic spot in the opposite half of the field of vision, which produces no 
subjective symptoms and is recognized objectively with difficulty or not at all. 
Ouly accurate clinical observation of the manner in which, in such a case, the 
hemianopsia recovers and what part of the field of vision is finally obliterated, 
will render a local diagnosis possible. Otherwise we have only the clinical 
diagnosis of no hemianopsia at the time of examination, and the anatomical 
finding of a small spot of softening at the periphery of the visual sphere {vide, 
for example, Henschen, I. c, Cases 27 and 28). No case has been reported of 
actual destruction of the "visual sphere" in man, without the corresponding 
homonymous disorder of vision. 

Bilateral destruction of the visual sphere produces total cortical 
blindness — bilateral hemianopsia. But hemianopsia on both sides 
does not lead necessarily to complete blindness. In two very similar 
cases' (Foerster, Arch. f. Ophth., XXXVI, 1, and Schweigger, 
(Arch. f. Augenheilk., Bd. XXII) typical hemianopsia with reten- 
tion of a small zone around the point of fixation occurred first upon one 
side, probably as the result of embolic softening. Subsequently this 
also developed on the other side. Instead of complete blindness there 
was left a small field of vision (onl}^ a few degrees in diameter) which 
enclosed the point of fixation, and in which there was comparatively 
good central vision. Foerster draws the conclusion that it is not 
necessary to assume a connection of the macular fibres with both 
hemispheres. This is true ; the above assumption is not necessary 
to explain the so-called residual part of the field of vision. It is 
sufiicient that the macular portion of the cortex, the perceptive cen- 
tre, obtains its blood supply from two arteries, so that on closure of 
one the supply necessary to the nutrition and function of that part of 
the cortex may be furnished collaterally. Nevertheless there may 
be a distribution of the macular fibres of both eyes to both visual 
spheres, and this appears probable to me for other reasons. Individual 
differences must occur in both assumptions. In one they affect the 

^ This category probably includes Berger, Bresl. aerztl. Zsch., 1885, No. 1, 
audGroenouw, Arch. f. Psych., 1891, p. 339. 



62 THE EYE IN RELATION TO DISEASE. 

distribution of the blood-vessels, in the other the distribution of the 
fibres (or both) to the cerebral cortex. The residuum of the field of 
vision may be color-blind (Foerster) or sensitive to color (Groenouw) ; 
in the latter case a larger part of the field of vision had been spared. 
As a matter of course the entire visual cortex is not destroyed in such 
cases. 

Diseases of the brain exhibit a tendency to occur symmetrically in 
both hemispheres, although not always at the same time on both sides, 
and often with quantitative differences. For example, Edinger 
{Deutsch. Zscli. /. Nerv.^ 1, p. 265) reports a case of bilateral soften- 
ing of the occipital lobes in which suddenly a dazzling light was per- 
ceived and then permanent complete blindness set in. Apart from 
diffuse processes which involve the surfaces of the occipital lobes (for 
example, in so-called ureemic and diabetic cortical blindness), blind- 
ness as the result of the successive or simultaneous development of 
hemianopsia on both sides may be due to embolism, hemorrhages, 
even tumors. The cortical disease on both sides may also be partial 
and may give rise, for example, to loss of both upper halves of the 
field of vision on account of destruction of the posterior halves of both 
visual spheres of the occipital cortex. Heche's very interesting case 
{Arch. f. Psych. ^ XXIII) of bilateral hemianopsia inferior in an 
insane patient, with hallucinations in the intact field and like phe- 
nomena in the blind field, was only observed clinically. The occur- 
rence of visual hallucinations points to an affection of the corona 
radiata. 

We have already considered those cases in which only an homony- 
mous section of each visual field has been lost. There are also some 
which are confined apparently to color perception (so-called color 
hemianopsia or hemiachromatopsia). When this is central in char- 
acter it must also be homonymous, i.e., it must have the same posi- 
tion in the visual field of both eyes. 

Cases of this category are quite rare. In pure cases the bound- 
aries are normal, or almost normal, and so likewise is central vision. 
The color hmits either pass vertically through the point of fixation or 
they leave a spot around it free, as happens so often in complete 
hemianopsia. It is an astonishing fact that in such cases very little 



DISEASES OF THE NERVOUS SYSTEM. 63 

attention has been paid to the "overlapping" color field. Bjerrum 
{Centralbl. f. Augenheilk., 1891, p. 120) has shown that whenever 
there was disturbance of color in the field of vision, a disorder of 
vision could also be demonstrated if the objects examined were suffi- 
ciently small. This was even true of a case which, with the ordinary 
method of examination, had appeared to be pure hemiachromatopsia. 
A relative amblyopia in the peripheral parts will be disclosed most 
readily, as in cases of complete hemianopsia, when situated on the 
right side on account of the interference with reading to which it 
gives rise. Hence such cases offer the first incentive to an examina- 
tion in regard to the diminution of peripheral vision. In fact, 
Eperon {Arch. d'Ophth., 1881, p. 356) and Verrey {Arch. d'Ophth., 
1888, p. 289), who mention hemiamblyopia in connection with the 
disturbance of color, had to deal with cases of right hemiachroma- 
topsia. 

Diminished function of the visual sphere thus seems to produce 
the same disturbance of color sense as interference with conduction 
in the optic nerve. Central vision is good, on account of the better 
supply of vessels to the macular part of the cortex {vide Foerster's 
and Schweigger's above-mentioned cases on p. 61), and on account of 
the presence of a concurrent part of the field of vision. At the periph- 
ery vision is diminished to correspond with the perception of colors ; 
there is relative amblyopia, w4th normal or nearly normal external 
boundaries. Thus there is no color disturbance without a corre- 
sponding disturbance of sight. 

If this is true, we do not need to assume with Eperon that, in the 
cerebral cortex, the elements for the light, space, and color sense lie 
in juxtaposition like the squares of a chess-board, nor with Wilbrand 
that they are distributed above one another, in the above-mentioned 
order, in the occipital cortex, so that those for the color sense are 
situated to the outside. According to the latter writer hemiachro- 
matopsia is due to superficial disturbances of the cortex, but anatom- 
ical proof of this statement is entirely wanting. We need merely 
assume that the function w^ithin the cortex is not abolished, but merely 
disturbed or rendered difficult, — interference with conduction in the 
neuropilemma, — or that the ganglion cells exhibit diminished function 



64 THE EYE IJT RELATION TO DISEASE. 

and capacity for reaction, which are temporary and may also remain 
stationary. 

The occurrence of total hemianopsia with color-blindness of the 
intact half of the field of vision (Schoeler, in Michel's " Jahresber." 
1884, p. 386, twice among fifteen cases), or of hemi achromatopsia, 
together with loss of an homonymous quadrant of the field of vision 
(Swanzy, Lancet^ 1883, II, p. 103), is thus explained much more 
simply and by a single lesion which abolishes the function of one 
visual sphere and merely impairs that of the other. 

If no overlapping area of the fields is present, then the disturbance 
of central vision in hemiachromatopsia will also be much more 
noticeable, as, for example, in Verrey's case {I.e.) of hemorrhagic 
cyst in the lower part of the occipital lobe. 

Hemiachromatopsia may also be peripheral in character — for ex- 
ample, in neuritis of one optic tract. If it is binasal, i.e., confined 
to both inner halves of the field of vision, as in Galezowski's case 
{Gaz. Med., 1880, p. 163), it is certainly peripheral (chiasm), and also 
when it is unilateral. 

A temporary disturbance of nutrition must be assumed in a typical 
hemianopic disorder, the so-called scintillating scotoma (teichoscopia, 
amaurosis partialis fugax, etc., preferably called hemianopsia com- 
pleta or incompleta scintillans) . It is probably due to spasm of the 
artery supplying the occipital lobe (posterior cerebral arterj^). This 
furnishes a certain connection with migraine, to which scintillating 
scotoma exhibits great resemblance. French writers often term it 
"migraine ophthalmique." 

After lively scintillation the field of vision contracts to complete 
or incomplete hemianopsia, or the point of fixation is chiefly affected. 
The scotoma is always strictly homonymous and negative, i.e., it 
does not appear dark or black. This disorder of vision may last 
from a few minutes to half a day, either alone or in combination 
with headache (migraine), nausea, etc. It is very rarely present on 
both sides at the same time, and then causes temporary cortical blind- 
ness, which is easily recognized, however, on account of the char- 
acteristic scintillation. This was observed on several occasions by 
my former teacher, Professor Horner. Per se the affection is harm- 



DISEASES OF THE NERVOUS SYSTEM. 65 

less. On account of its great frequency it is often said to be con- 
nected with material diseases of the eye, for example, with glaucoma. 
This is decidedly incorrect, because glaucoma, which is almost al- 
ways bilateral, is surely not related to a unilateral disorder of the 
cerebral cortex. It would be more likely to be associated with brain 
disease, but this is also very rare. It is often merely a symptom of 
insufficient nourishment, for example, in individuals w^ho do not eat 
anything until noon, and its development is also favored by mental 
strain. 

Irritation of the cortex of the visual sphere causes visual hallu- 
cinations, 2.e., subjective visual perceptions varying from simple to 
quite complicated processes. The visual hallucinations are usually 
present on both sides, but they may also be confined to one-half of 
the field of vision (homonymous hemiopic hallucinations) and then 
develop in the opposite visual sphere. 

Half-sided hallucinations are observed most frequently in mi- 
graine, epilepsy, and hemiplegia, more rarely in other brain diseases, 
including insanity. Usually — especially in the first-named diseases 
— there is also hemianopsia and the hallucinations are seen upon the 
blind half of the field of vision. The}' also occur when the functions 
of the central visual apparatus are, in other respects, entirely normal. 

In irritation of one visual sphere conjugate deviation of the eyes 
to the opposite side is also observed ; this will be discussed later. In 
unilateral visual hallucinations we often find conjugate deviation of 
the eyes toward the supposed site of the hallucinations. 

Whether central disorders of vision are ever unilateral is still an 
open question. For example, Charcot regards the majority of the 
unilateral hysterical disorders of vision as central, and explains them 
by decussation of the uncrossed visual fibres on the central or cortical 
side of the peripheral optic ganglia. Such an assumption has no 
anatomical justification. This does not combat the view that uni- 
lateral visual disorders may be produced by unilateral irritations and 
destructions of the brain (Lannegrace). Here we have to deal prob- 
ably with disorders of circulation which, provoked by a lesion of the 
brain, exercise their effect upon peripheral parts of the visual fibres. 

A disease of the frontal lobe, which implicates the optic nerve on the 
5 



6Q THE EYE IN RELATION TO DISEASE. 

same side, causes merely a peripheral disorder of vision, despite the 
fact that the cause is located in the central organ of the nervous 
system. We will enter more fully into this question in the consider- 
ation of hysterical disorders of vision. 

2. In central disorders of vision the ophthalmoscopic appearances 
are normal. The ganglion cells which perish in the primary optic 
centres do not send axis cylinders into the optic nerves. Atrophic 
degeneration of the optic nerve is therefore not seen with the ophthal- 
moscope, especially as the function of the nerve, as we shall soon see, 
is not entirely abolished in destruction of the visual cortex. On page 
14, we have considered the exceptions in which finally the degenera- 
tion does become noticeable at the periphery. 

Cases of ophthalmoscopically visible bilateral atrophy of the optic 
nerves and total blindness with intact pupillary reaction to light, as 
in Jessop's case {Lancet, July 11th, 1891, p. 73), may be explained on 
the assumption that the ophthalmoscopic picture of atrophy of the 
optic nerve also occurs when vision is good, and that the symptoms 
in question must follow, if a central disorder of vision is superadded. 

3. In all central disturbances of vision the involuntary and un- 
conscious reflexes on illumination of the insensitive parts of the field 
of vision remain intact, particularly the movements of the pupil to 
light. These are most easily observed and tested. The direct and 
consensual pupillary reactions to light are retained, despite the fact 
that the latter produces no sensation of light from the corresponding 
part of the field. Hence, in central hemianopsia the pupillary reac- 
tion will be the same whether the light enters the eye from the seeing 
or the blind half of the field of vision, while in the much rarer hemi- 
anopsia from disease of an optic tract no pupillary reaction to light 
follows on illumination within the blind half of the visual field (hemi- 
anopic pupillary reaction). This symptom must be specially looked 
for, particularly when we have to deal, not with hemianopsia, but 
with smaller homonj^mous defects in the field of vision. In complete 
bilateral cortical blindness the reaction of the pupils to light, despite 
the complete absence of all perception of light, is extremely striking 
and has long been known (Graefe). 

Other involuntary light reflexes are observed with much more 



DISEASES OF THE NERVOUS SYSTEM. 67 

difficulty. We should notice whether, in the field of an homonymous 
scotoma, very sudden and intense light stimuli are capable of produc- 
ing involuntary movements of the eyes and head toward or from the 
source of light, closure of the lids, etc. This can be shown most 
clearly when the central disorder of vision is bilateral, i.e., in cortical 
blindness. 

I have observed one case of bilateral central blindness (urjemic 
blindness in a boy of about ten years) in which, apart from the intact 
pupillary reaction to light, movement of the eyes and head toward 
the source of light occurred on the entrance of direct sunlight from 
the side ; on the entrance of light from the front, closure of the lids 
followed, although the patient had not the faintest perception of 
light. 

But the involuntary reflexes from the visual organ (and also prob- 
ably from other higher organs of sense, for example, the ear) evi- 
dently play no great part in man, particular!}^ in adults. Apart from 
the pupillary movements, which are independent of the will, they 
are replaced mainly by conscious and voluntary?; movements which 
are intended, in general, to effect the same objects as the involuntary 
reflexes; viz., adjustment of the eyes upon an object which appears 
in the field of vision, looking away from the object, closure of the 
lids in a bright light, etc. It is not impossible, especially in adults, 
that these involuntary reflexes from the visual organ which are sub- 
ject to outside influence are almost entirely suppressed by practice 
and experience and that they only take place after very unexpected, 
sudden, and intense light stimuli (fright). This readily explains the 
fact that the involuntarj^ light reflexes were especially striking in my 
youthful patient. Further investigations in this direction would be 
very interesting. 

Reflexes to more minute visual stimuli, such as the approximation 
of a needle or a finger to the eye, do not belong to this category, be- 
cause they require actual seeing, differentiation and judgment of ob- 
jects. Such movements are conscious and performed with the aid of 
the occipital cortex. We will again refer to these conditions. 

Central disorders of vision from lesions in the corona radiata of 
the occipital lobe (Gratiolet's optic radiations) will be very similar to 



68 THE EYE IN RELATION TO DISEASE. 

those caused by lesions of the occipital cortex. The onty possibility 
of differentiation — unless other local symptoms are present — is fur- 
nished by the presence of visual hallucinations. These presuppose a 
visual cortex which is still capable of function. Hence, if visual 
hallucinations on the blind side are present in hemianopsia (with 
intact pupillary reaction on illumination of the blind half of the field 
of vision) , the lesion is situated within the corona radiata, and the 
cortex of the visual sphere is still exercising its function to a greater 
or less extent. If this symptom is absent, a differential diagnosis is 
impossible unless the accompanying conditions furnish some data. 

It would be advisable to employ special technical expressions for 
the different kinds of central and peripheral visual disorders. I 
would recommend that amblyopia and amaurosis be used solel}^ for 
peripheral (and the rare intermediate) disorders, and the words 
terminating in "opsia" for central disorders of vision. In the former 
the light reflexes of the pupil are also disturbed, and atrophic changes 
in the nerve, which are visible with the ophthalmoscope, usually oc- 
cur sooner or later;, in the other forms, this is not true. The visual 
disorders of the tractus and those which are located in the chiasm 
would then be called hemiamaurosis and hemiamblyopia (homony- 
mous, binasal, bitemporal, incomplete, symmetrical). Hemianopsia 
would be reserved for central half -blindness and would always be 
homonymous. Anopsia would mean central blindness (cortical 
blindness), and the term miopsia (= seeing less) could be introduced 
for central diminution of vision. Hemimiopsia would then mean 
those cortical homonymous disorders of vision which do not amount 
to complete hemianopsia. 

Before proceeding further in the discussion of the central disor- 
ders of vision, we must trace, if possible to the cortex, the motor and 
sensory disorders of the eye which, as we have seen, are never purely 
motor, purely sensory, or purely sensorial. A critical sifting of the 
different theories with regard to localization in the cerebral cortex is 
only possible after the fullest possible recognition of the relations of 
the latter to the centripetal and centrifugal tracts. 



diseases of the nervous system. 69 

2. Disorders of the Voluntary Ocular Muscles. 

The muscular disorders consist of paralyses and spasms, in part 
of a very peculiar and characteristic kind. In general spasms play 
a subordinate part ; they are due to irritation of those parts whose 
destruction would cause paralysis. Hence, spasms and paralyses 
furnish the same local diagnosis. In many cases the spasms are 
merely the first stage of a subsequent paralysis of the muscle.' 

The paralj'ses, like the disorders of vision, may be peripheral, in- 
termediate (nuclear), and central. We speak of paralj'sis when the 
affection is unilateral and the paralyzed muscle or muscles are sup- 
plied by a single nerve ; all other cases are known as ophthalmoplegia. 
This distinction, however, is not always carried out strictly. 

a. The peripheral paralyses are characterized by the fact that the 
voluntary as well as the involuntary movements of the muscle are 
abolished. The so-called degeneration reaction appears very early and 
the nerve-fibres degenerate, together with the ganglion cells of the 
nuclei from which they originate. Finally, the muscular fibres also 
undergo fatty or connective-tissue degeneration (really only two stages 
of the same process), as the result of which secondary changes 
(secondary contractions, etc.) usually set in. Recovery will take 
place only when conduction has been abolished temporarily, not when 
it has been interrupted or destroyed for too long a period. 

The peripheral paralyses of the ocular muscles may be thus located : 
1. Intra-ocular (iris and ciliary muscle), for example, in injuries. 2. 
Within the orbit ; the muscles themselves or the nerve trunks and 
twigs may be affected. 3. Intracranial, within the skull to the en- 
trance of the nerve trunks into the brain, -i. Within the brain itself 
(fascicular, Mauthner and Dufour; preferably called root paralyses), 
between their entrance and their termination in the nuclei whose 
position has already been described. We will devote only a brief 
space to the peripheral paralyses. Their location will be inferred 
mainly from the accompanying circumstances, the coexistence of 
other disorders, etc. 

An orbital cause is probable if the inferior oblique and the internal 
ocular muscles alone are affected, because the latter receive their 



70 THE EYE IN RELATION TO DISEASE. 

nervous supply from the branch of the motor oculi which passes to 
the inferior oblique {vide p. 27). Otherwise the conclusion depends 
mainly on the complications, such as exophthalmus, unilateral or 
bilateral character, number and kind of the muscles. Primary affec- 
tions of the muscles are rare and usually diagnosed with difficulty 
unless oedema of the insertion of the muscle into the eye, pain on at- 
tempting movement, etc., point to such a condition. In orbital in- 
flammation the eye is more or less immovable, either as a whole or 
chiefly toward one side. Exophthalmus is present or the eye is 
pushed forward toward the side opposite to that in which movement 
is abolished. A similar condition is observed in orbital tumors. 
There is often coincident disorder of sight and even complete blind- 
ness. After a certain lapse of time atrophic conditions may be found 
at the entrance of the optic nerves. Pressure on the eye is almost 
always painful. The internal ocular muscles may escape when the 
cause of paralysis is situated within the orbit. 

In congenital paralyses the muscle in question is very often absent 
(usually the levator palpebrse superioris [congenital ptosis], more 
rarely the superior rectus or some other muscle). 

Intracranial or basilar paralyses are not easily diagnosed if only 
a single nerve is involved. In many cases several adjacent nerves 
at the base of the brain are implicated, particularly those on the same 
side, or disorders are found in the distribution of the olfactory, optic 
tract, chiasm, etc. (meningitis, tumors, aneurism). Paralysis of the 
motor oculi with exemption of the internal ocular muscles can hardly 
be basilar. On the other hand post-mortems have shown that the 
majority of so-called " periodical" paralyses of the ocular muscles are 
basilar in character (multiple neuritis of the nerve roots and origins). 

Fascicular location of a paralysis (root paralysis) is assumed, for 
example, when an ophthalmoplegia {vide above) is complicated with 
crossed hemiplegia, because in the cerebral peduncle the roots of the 
nerves of the ocular muscles intermingle with the still uncrossed 
motor portion of the former. The decussation of the motor fibres in 
the pes pedunculi only takes place in the medulla (decussation of the 
pyramids). Such paralyses are extremely rare without coincident 
lesion of the nucleus. 



DISEASES OF THE NERVOUS SYSTEM. 71 

Peripheral paralyses which furnish no data whatever concerning 
their cause or location are not very frequent. They are then usually 
called "rheumatic." 

h. The so-called nuclear paralyses present, like peripheral paraly- 
sis, total suspension of the voluntary and involuntary movements ; in 
them, likewise, the nerve and muscle degenerate at an earlier or later 
period. The degeneration cannot be followed farther centrally, al- 
though the cerebral cortical cells, whose terminal network of fibres 
in the nerve nuclei is destroj^ed, are undoubtedly also destroyed. It 
is evident that the fibres which pass from the cortex to the nuclei of 
the ocular muscles, and indeed all the centrifugal fibres which pass 
to the latter, do not run in dose bundles. Nor do they originate in a 
circumscribed part of the cortex, because otherwise degenerations 
would be found in the corona radiata and the cerebral cortex. 

In the diagnosis of nuclear paralysis as distinguished from the 
peripheral forms, the anatomical conditions of the nerve nuclei are 
especially decisive {vide Figs. 5 and G). For example, if the 
sphincter pupillse of only one eye is paralyzed and all the other 
muscles of that motor oculi nerve act normallj^, this can hardly be 
explained by anything but a nuclear affection (apart from local 
drugs). The diagnosis is still more positive when the sphincters of 
both pupils, whose nuclei lie close together, are alone paralyzed. 
When the cause is in the nuclei, only single muscles of one or both 
motor oculi nerves will be affected, for example, isolated ptosis. It 
not infrequently happens that only the internal or the external 
muscles of one or both eyes (internal or external ophthalmoplegia) 
will be involved or that similar muscles are paralyzed in both eyes. 
Isolated paralysis of the internal ocular muscles of one qjq may also 
be due to ocular (atropine, trauma) or intraorbital causes; for ex- 
ample, destruction of the ciliary ganglion, which would also produce 
anaesthesia of the cornea. In such cases, however, sufficient diagnostic 
and anamnestic data can usuall}" be found. The diagnosis is often 
more difficult in so-called multiple neuritis, especially root neuritis, 
when only individual bundles of the motor oculi degenerate, and 
when, as sometimes happens, this is almost symmetrical on the two 
sides. In fact, several cases which were diagnosed during life as 



72 THE EYE IN RELATION TO DISEASE. 

nuclear paralysis were found, on autopsy, to be basilar in character, 
or the findings were entirely negative (Eisenlohr, Neur. CentralhL, 
1887, p. 337). 

The diagnosis is positive when a slowly progressive process at- 
tacks the ocular muscles in the order in which their nuclei are 
arranged anatomically alongside of one another. This may occur in 
an ascending or descending direction, so-called progressive paralysis 
of the ocular muscles or superior polio-encephalitis (Wernicke) as 
opposed to inferior polio-encephalitis or bulbar paralysis which is a 
closely allied process. Nevertheless, these two forms of disease do 
not often pass into one another. An exhaustive monograph on 
chronic progressive paralysis of the ocular muscles has been fur- 
nished by Siemerling (Arch. f. Psych, u. Nerv.^ 3d. XXII, Sup- 
plement) from which it appears that the disease is not a unit. It 
is generally a nuclear affection, but the anatomical appearances may 
vary greatly. 

From an analysis of two hundred and twenty cases Dufour dis- 
tinguishes acute and chronic forms of nuclear paralysis. The chronic 
cases may remain stationary for ten years or they may be slowly 
progressive. In the latter event they may be confined to the principal 
nucleus or, beginning at other muscle nuclei, they may extend to those 
of the eye, or they may follow the opposite direction. ^N^uclear 
paralysis may complicate bulbar paralysis, progressive muscular 
atrophy, tabes, disseminated sclerosis, or it may constitute the initial 
symptom of tabes. Of the hitherto known cases of periodical paraly- 
sis of the ocular muscles {vide the cases collected by Moebius, 
Schmidt's Jahrh., Bd. 207, p. 244) Dufour regards only four as 
surely of nuclear origin (Pflueger, Tagebl. d. Naturforsch.-Ver- 
samml. z. Strasshurg^ 1885, p. 491; Vissering, Muench. med. Woch., 
1889, p. 699; Camuset, Gaz. des Hop., 1875, p. 259, and Dubois). 
All others are probably due to a basilar cause which was found in 
every case in which an autopsy was obtained (exudation around the 
motor oculi, Gubler; eruption of tubercles in this region, Weiss; 
fibrochondroma of the nerve, Richter) . 

Among the acute nuclear paralyses there is one severe form which 
usually proves rapidly fatal. This is due generally to an acute 



DISEASES OF THE NERVOUS SYSTEM. 73 

hemorrhagic polio-encephalitis at the floor of the fourth ventricle (in 
drinkers), but solitary tubercles or a cyst (Bull) have also been rec- 
ognized as causes. Sometimes the post-mortem findings were en- 
tirely' negative (Eisenlohr, I. c, etc.). The benign acute form in- 
cludes almost the half of all known nuclear paralyses. This variety 
may be due to injuries, chemical poisons, constitutional anomalies, 
acute and chronic infectious diseases (for example, paralysis of ac- 
commodation after diphtheria). 

In those cases of nuclear paralysis in which autopsies were ob- 
tained there were usually found hemorrhages or hemorrhagic in- 
flammations of the nuclei, much more rarely acute or chronic inflam- 
mation or simple atrophic degeneration. In one-sixth of the cases 
ihe findings were negative. The complete bibliography will be found 
in the two principal works on nuclear disorders of the ocular muscles, 
by Mauthner, Wiesbaden, 1885, and Dufour, Annal. d' Oculist., 
1890, p. 97. 

The congenital absence of muscles and congenital paralyses are 
probabl}' always due to intra-uterine peripheral or nuclear causes. 
Moebius (Muench. med. TVoch., 1892, ISTos. 3 and 4) states that in 
so-called '* infantile atrophy of the nuclei," the facial nerve is also 
often affected, but not the internal ocular muscles. After the process 
has run its course, it can hardly be decided whether the nucleus, 
nerve, or muscle was primarily affected. 

The very rare symptom that one eye is deflected downward and 
outward, the other inward and upward, points to the nuclear region 
or at least to its immediate vicinity. According to ISTothnagel it is a 
focal symptom of disease of the middle crura cerebelli. 

c. Central Disorders of the Voluntary Ocular Muscles. — On 
the central side of the nuclear region the motor fibres no longer run 
in bundles. Hence the anatomical demonstration of their course is 
practically impossible, and this must be inferred, in the main, from 
non-anatomical premises. 

We have intentionally used the term " disorders" because, as in 
all central paralyses, we have to deal, not with complete paralysis, but 
merely with disorders of motion, i.e., with the loss of certain quali- 
ties of motion. 



74 THE EYE IN RELATION TO DISEASE. 

In a motor nerve nucleus we find, apart from the connective-tissue 
constituents and the vessels : 

1. Motor ganglion cells, whose axis-cylinder processes form the 
motor nerves. 

2. Networks of nerve fibres (neuropilemma). The latter un- 
doubtedly has different origins. For the nuclei of the ocular muscles 
the following three sources of origin can be demonstrated : 

a. Fillet fibres which convey sensory impressions from the op- 
posite half of the body to the nuclei of the ocular muscles. This con- 
nection evidently subserves the involuntary ocular movements after 
sensory impressions from the opposite half of the body; associated 
deviation of the eyes (and head) toward the approximate position of 
a tactile impression, etc. The great mass of the fillet fibres passes to 
the optic thalamus. 

h. Tractus fibres from the anterior corpora quadrigemina (Mey- 
nert's fibres), corresponding to the opposite half of the field of vision. 
These subserve the involuntary ocular movements after impressions 
of light from the opposite half of the field of vision ; these are also 
conjugate movements of adjustment ; a and h are centripetal tracts. 

c. The third place from which fibres pass to the nuclei of the 
ocular muscles is the cerebral cortex, particularly the visual sphere 
in the occipital lobes, in whose corona radiata they run. These are 
centrifugal tracts. 

It is an astonishing fact that definite relations have not been dis- 
covered jet ween the ocular movements and those parts of the cortex 
which are called "motor." A definite relation exists only between a 
spot in front of the upper extremity of the anterior central convolu- 
tion (viz., Fig. 8, 1) and the levator palpebrse superioris and orbicu- 
laris palpebrarum, i.e.^ with movements of the eyelids, not of the 
eye itself. 

Ocular movements toward the opposite side (conjugate deviation) 
can be obtained occasionally on irritation of almost all parts of the 
cortex of a hemisphere, but this can be done most certainly from the 
cortex of the occipital lobe, ^^e., from the visual sphere. The in- 
vestigations of Munk and Schaefer in particular have shown that 
irritation of one visual sphere with a feeble induced current causes 



DISEASES OF THE NERVOUS SYSTEM. 75 

associated movements of both eyes toward the side opposite to the 
irritation. The eyes are also directed downward when the irritation 
affects the anterior zone of the visual sphere, and upward w^hen in 
the posterior zone. Under certain conditions, dependent upon the 
site of irritation and the position of the eyes, there are (apparently) 
no associated movements, but movements of adduction of one or both 
eyes (convergence !) or a continuance of the eyes in the same position. 




Fig. 8.— The Left Motor Cortical Centres in Man, after Bergmann. SR, Sulcus of Rolando; 
ns, fissure of Sylvius; 8F0, parieto-occipital sulcus; F^, F^. F^, first, second, third, frontal 
convolution; VC and HC, anterior and posterior central convolutions; Tj, Tj, first, second, 
temporal convolutions (T<2, auditory centre; Tj, Wernicke's convolution, so-called); GA and 
GSM, angular gyrus and supra-marginal gyrus, both together form the inferior parietal lobe; 
Z, cuneus; PC, praecuneus; 1, oculomotor (levator palpebrae superioris) ; 2, hypoglossus; 3, 
motor speech centre ; 4, oral part of facial ; 5, facial part of same ; 6, 7, 8, 9, upper extremity 
(6, abductors; 7, flexion, supination, and pronation-motor writing centre; 8, exftlhsors); 10, 
lower extremity. 

Obregia {Arch. f. Anat. u. Phys., 1890, p. 260) arrives at essentially 
the same results. He also noted the important fact that irritation of 
the macular region of the visual sphere hardly excites any move- 
ments, but that the conjugate movements of the eyes toward the op- 
posite side become much more extensive, the more the periphery of 
the visual sphere is approached. These are evidently conjugate 
movements of adjustment of the eyes. The visual sphere contains a 
motor projection field for movements of adjustment of the eyes, so 
that, on irritation of a definite part, that conjugated movement is 
prod.i>ced which turns the fixation point of both eyes toward the 



76 THE EYE IN RELATION TO DISEASE. 

corresponding point in the opposite half of the field of vision. If 
the irritation affects the macular region of the visual sphere, no 
movement follows; the irritation appears to come from the point 
of fixation, and this can only happen when the eyes are already 
adjusted. 

These ocular movements also take place when the associative fibres 
to the motor cortex are divided, and the occipital lobe, in a measure, 
is isolated (Munk, Centralb. f. Augenheilk., 1890, p. 149). The 
muscle nuclei are accordingly stimulated along the direct path of the 
corona radiata, and both eyes are always impelled to perform con- 
jugate movements. 

These experiments agree with clinical observations, in which irri- 
tation of one hemisphere causes conjugate deviation toward the oppo- 
site side; paralysis causes abolition of the voluntary conjugate 
movements toward the opposite side. If the other hemisphere is 
in a condition of irritation at the same time, it will cause conjugate 
deviation toward the site of disease. Newman (Berl. kl. Woch., 
1890, p. 403) published an apparent exception to this rule. In his 
case there was a hemorrhage into the frontal lobe. But this does 
not necessarily cause paralysis of the entire hemisphere. Indeed, 
those parts of the cortex which are remote from the lesion — in this 
instance the occipital cortex — will be more apt to be in a condition 
of irritation. Hence it is not astonishing that the eyes were de- 
flected to the side opposite to the lesion. Such exceptions merely 
prove the rule. 

The influence of the inferior parietal lobe on the conjugate move- 
ments of the eye (Wernicke) is easily explained by its close prox- 
imity to the periphery of the visual sphere, which has a special 
motor efficiency and whose destruction causes only slight disturbance 
of vision (vide p. 59). 

The ocular movements which Munk obtained in his experiments 
by stimulating the visual sphere he regards as the lowest visual re- 
flexes, which do not presuppose visual perceptions but merely sensa- 
tions of light. In fact the movements obtained in such an experi- 
ment are involuntary. In my opinion, however, the performance of 
these movements takes place along those tracts which, in the normal 



DISEASES OF THE NERVOUS SYSTEM. 77 

condition, convey the voluntary movements of the eyes after con- 
scious visual impressions. 

In the visual sphere the afferent optic and the efferent motor 
fibres are distributed in such a way that irritation of any part of a 
visual sphere adjusts both eyes in the same way as if an object, 
appearing at the corresponding spot in the opposite half of the field 
of vision, were fixed binocularly. Hence, the optical cerebral cortex 
is at the same time the motor centre for the voluntary ocular move- 
ments, in so far as the latter are provoked by conscious light im- 
pressions. Each visual sphere controls these movements chiefly in 
the domain of its half of the field of vision on the opposite side. 

In Obregia's experiments the conjugate movements of the eyes 
were so much more extensive, the more peripheral the site of irrita- 
tion. A peripheral position in the visual sphere corresponds to a pe- 
ripheral part of the opposite half of the field of vision. The farther 
the image of an object is from the point of fixation, the more exten- 
sive, as a matter of course, must be the conjugate movement of the 
eyes necessar}' for adjustment. If the image of an object falls upon 
the fovea centralis of the retina and is conducted thence to the macu- 
lar portion of the visual sphere, no conjugate movement will result 
because the eye is already adjusted. Now convergence and accom- 
modation for the object are alone necessary, and for these two move- 
ments — viz., the fine adjustments of the eyes which are already turned 
in the general direction of an object — which take place under the 
control of conscious vision, we must regard the macular portion of 
the visual sphere as the cortical centre ; from its periphery are pro- 
duced voluntary associated movements after conscious light impres- 
sions and also under the control of conscious vision. 

As the nucleus of the motor oculi of one side sends its fibres to 
all the muscles which are innervated in conjugate movements of 
both eyes toward the opposite side {vide p. 22) , as the roots of the 
trochlearis decussate while those of the abducens do not, each visual 
sphere stands in centrifugal connection mainly with the nuclei of 
the motor oculi and trochlearis on the same side, and with the oppo- 
site abducens nucleus. But if it is subsequently proven that the 
root fibres of the abducens nucleus do decussate, as is positively 



78 THE EYE IN RELATION TO DISEASE. 

maintained by some writers — this is denied with equal positiveness 
by the majority of writers, but it is certain that numerous fibres 
between the two nuclei undergo decussation — then the visual sphere 
would be in centrifugal connection essentially with the nuclei of 
the ocular muscles on the same side. In the main the macular 
locality of the visual spheres would send its motor fibres to nuclei 
8 and 3 of Fig. 6 (p. 18), which are employed in convergence and 
accommodation. From this part contraction of the pupil as an 
" associated movement" must also be provoked, and this, as a matter 
of course, is bilateral. The cortical impulse for accommodation and 
convergence, likewise, is always equally strong for both eyes. 

All movements which are excited by the cortex affect both eyes 
and are associated and conjugate; this was also found to be true of 
the involuntary reflex movements. 

If a visual sphere is destroyed, then, apart from the consequent 
disturbance of vision, the following phenomena will be produced : 

1. The voluntary ocular movements after light impressions with- 
in the lost half of the field of vision are abolished. It goes without 
saying that when an object is not seen, adjustment upon it will not 
be made, and that the disturbance of motion will be entirely over- 
looked on account of the disorder of vision. If the object were visi- 
ble there is no doubt that voluntary adjustment of both eyes would 
take place. In addition it is to be noted that not all the conjugate 
ocular movements toward the side of the lost half of the field of 
vision are abolished, but only in so far as they are induced by con- 
scious visual impressions. This disorder of motion is capable of 
direct demonstration. If I attempt to imitate the visual disorder in 
right hemianopsia by attempting to read immediately behind a 
screen, this is indeed made somewhat difficult, but not by any man- 
ner of means to the same extent as in cortical right hemianopsia. 
As the visual disturbance in both cases is the same, this difference 
can only be explained by a disorder of motion ; the aid of the con- 
stant movements of adjustment which are excited by peripheral 
visual impressions, and which are necessary for fluent reading, are 
lacking. The voluntary ocular movements toward the opposite 
side, which are excited from other parts of the cortex, are only ap- 



DISEASES OF THE NERVOUS SYSTEM. 79 

proximate and only replace imperfectly the movements performed 
with the aid of the occipital cortex; hence also the rapid ex- 
haustion. 

In the same way that the visual sphere is active optically and 
oculomotorially, the auditory sphere is active acoustically and oto- 
motorially. According to Baginsky irritation of the auditory sphere 
with feeble electrical currents also excites movements of the ears, 
even dilatation of the palpebral fissure, which I can only compare with 
those observed in listening. The so-called motor region also con- 
tains an abundance of sensory fibres, in great part from the optic 
thalamus (whose ganglion cells perish after destruction of the motor 
cortex (Monakow) . Hence the optic thalamus constitutes the inter- 
mediate ganglion of the motor cortex, analogous to the relation of 
the three primary optic ganglia to the visual sphere and (probably) 
of the internal geniculate body and posterior corpora quadrigemina 
to the auditory sphere. 

In circumscribed destruction of one visual sphere it is difficult to 
demonstrate the homonymous disorder of vision ; this is equally diffi- 
cult with regard to the consequent conjugate disorder of movement. 
This could be done more easily if the macular locality of one visual 
sphere were alone affected. The visual disorder is then slight be- 
cause the fixation point is intact in both eyes. On the other hand, 
the unequal motor innervation of the centre for convergence will also 
be made evident by the fact that the closely approximated images of 
both eyes can be made to unite with difficulty or not at all, a condi- 
tion usually known as imperfect fusion of the double images. I 
have observed this symptom as an entirely isolated temporary phe- 
nomenon which was substituted for an attack of scintillating sco- 
toma and was attended with the same subsidiary symptoms as the 
latter. In such cases the cortical location is undoubted. In others 
the lesions seem to be subcortical (corona radiata or vicinity of the 
muscle nuclei) as, for example, in the imperfect fusion which is an 
initial symptom of locomotor ataxia. The principal point is that the 
cortical innervation of the nuclear centre for convergence in the motor 
oculi nucleus does not take place uniformly from both macular locali- 
ties of the visual sphere. 



80 THE EYE IN RELATION TO DISEASE. 

2. In destruction of a visual sphere the following functions re- 
main intact : 

a. The involuntary reflexes after unconscious light stimuli, par- 
ticularly the reaction of the pupils to light on illumination of the 
blind half of the field of vision. Conjugate movements of the eyes 
and corresponding movements of the head, closure of the lids, etc., 
may also take place, despite the abolition of the perception of light, 
as is shown by my case mentioned on p. 67. b. Involuntary move- 
ments of the eyes after other than light stimuli (cutaneous irritants, 
noises, etc.). c. Voluntary movements of the eyes after other than 
light stimuli. The retention of the latter conceals, to the greatest 
extent, the disorder of motion in cortical hemianopsia, because they 
affect the same object as voluntary movements of the eyes after con- 
scious light perception (adjustment of the eyes toward the locality 
from which the stimulus starts) . But the conjugate movements of 
the eyes, without control of vision, are much more awkward — for 
example, those produced at the word of command. Under normal 
conditions it is sufficient that the movement of the eyes is an approx- 
imate one, that it brings the object in question into the field of vision. 
Then follows the fine adjustment with the aid of the sense of sight. 
The voluntary conjugate movements of the eyes (for example, those 
at the word of command) in the blind are remarkable from the 
fact that they again pass gradually and unconsciously into the posi- 
tion of rest (Kaehlmann) . 

As this voluntary innervation of the nuclei of the ocular mus- 
cles also takes place when the visual sphere is destroyed, their tracts 
cannot pass by associative fibres to the visual cortex and from thence 
through the corona radiata to the muscle nuclei, but they must pass 
directly to the latter. A few nerve fibres through which the eyes 
are incited to perform conjugate movements upward, downward, to 
the right or left, suffice for this purpose. The rest is done w^ith the 
aid of the visual cortex. It follows again that the cortex is nowhere 
purely motor, purely sensorial, or purely sensory, and that there is 
nowhere a localization in the strictest sense of the term, although 
in general certain parts of the cortex chiefly exercise certain func- 
tions, and the individual parts are nowhere absolutely co-ordinate. 



DISEASES OF THE NERVOUS SYSTEM. 81 

Binocular adjustment is learned by the child at the same time 
with the judgment of fixed objects, with the development of con- 
scious vision and the recognition of objects and processes of motion. 
The necessary fibrous connections between the retina and cerebral 
cortex, between the fovea centralis and the perceptive centre, only 
develop fully after birth and gradually become medullated and thus 
capable of function. If this development is disturbed for any rea- 
son, for example, by early acquired opacity of the refracting media, 
by the impossibility of perfect vision on account of congenital anom- 
alies, etc., then a peculiar disturbance of movement, viz., nystag- 
mus, is constantly noticed. By its conjugate occurrence this points 
to a cause which is situated centrally from the muscle nuclei. If 
visual disturbance or blindness begins in later life, the development 
of nystagmus is much rarer. Hence, nystagmus may be defined 
as imperfect cortical innervation of the voluntary muscles of the eye 
(as a peculiar form of cortical paralysis agitans). Its real cause 
may be peripheral, central, or both. 

If insufficient vision is obtained hj an eye from optical causes 
(opacity of the media, albinism, marked astigmatism), or because, 
for example, the fovea centralis cannot be utilized in fixation (early 
convergent squint, etc.), then the visual impressions from the cere- 
bral cortex do not suffice to excite, on the part of the visual cor- 
tex, an impulse to movement which is sufficiently intense to cause 
proper adjustment of the eyes. The motor cortical innervation is 
too feeble and assumes the character of paralysis agitans. Under 
such circumstance, it is also understood that the ocular movement 
does not correspond to an apparent motion of objects because the 
individual, so far as he remembers, has never seen otherwise and 
knows that the visible objects are not moving. The apparent rest 
of the objects despite the movement of the eyes is a psychical 
process. 

If the visual disorder is bilateral, the nystagmus is constant ; if 

it is unilateral, nystagmus is usually not present when an object is 

fixed with the good eye. But binocular nystagmus will develop 

forthwith when the poor eye is employed in fixation (strabismus con- 

vergens concomitans) . 
6 



82 THE EYE IN RELATION TO DISEASE. 

The visual disturbance in early strabismus convergens — unless this 
is alternating — is due to the fact that, from the squinting eye, the 
fibres from the macula lutea and fovea centralis are not connected in 
the normal manner with the macular locality in the visual cortex, but 
that this takes place from a peripheral part of the retina, upon 
which the image of the object looked at falls on fixation with the 
other eye. This peripheral part of the retina does not possess the 
organization of a fovea centralis, and hence the acuteness of vision 
is more or less diminished (vicarious macula). Nevertheless it occa- 
sionally happens that crossed double vision appears in the correct 
position of the eyes after the operation for strabismus, because rela- 
tive external squint now obtains for this acquired macular locality. 
Such cases, however, are quite rare. 

The disturbance of movement in the ordinary ambl3'opia of stra- 
bismus differs in no essential respect from the congenital or early 
acquired disorder of vision due to anatomo- pathological changes. In 
the latter (nystagmus proper) there is a constant pendulum move- 
ment around the position of equilibrium ; in the former there are 
twitching movements to one side. This form is preferably de- 
scribed as nystagmus -like twitchings. In both forms there is defi- 
cient cortical innervation. In true nystagmus there is a steady, con- 
stant, uniform disorder of innervation; nystagmus-like twitchings 
appear in unequal and changing disturbance of innervation, as, for 
example, in rapid cortical exhaustion after unusual or forced move- 
ments. The number of oscillations varies from two to ten in a 
second ; the average is four to five. The higher numbers correspond 
to the " tremor" of the eyes in alcoholics and cases of paretic demen- 
tia, the lower numbers to the " explosive" twitchings of the nystag- 
mus-like disturbance of movement. 

In nystagmus proper and also in the lesser twitchings we can 
distinguish a centripetal or optical form, a centrifugal or motor 
form, and a cortical form. As a matter of course, these cannot 
always be sharply separated, because there are mixed forms, even of 
all three, as in the nystagmus of miners. As the disturbance in the 
optical forms is usuall}^ constant and permanent, and often variable 
in the motor forms, this explains in a very simple manner the fact 



DISEASES OF THE NERVOUS SYSTEM. 83 

that true nystagmus is so often observed in the former, and usually 
nystagmus-like twitching in the latter. 

Nystagmus rarely begins in adults after unilateral or bilateral 
disturbance of vision from peripheral disease of the eye, but it may 
develop in other ways. The best known is the so-called nystagmus 
of miners, especially of coal-miners after protracted spells of work. 
Disturbance of vision is often present at the same time, such as dimi- 
nution of central vision, night-blindness, etc. The cause is the 
strain of the eyes in imperfect illumination, and constrained move- 
ments as in looking upward. Nutritive disturbances, chronic poi- 
soning with miasmatic gases, etc., are predisposing factors. It is 
easy to understand that, under such circumstances, an optical as 
well as a motor exhaustion of the cortex must set in. One or the 
other will predominate, according to circumstances. Hence, distur- 
bance of vision may be absent or slight, or the nystagmus may ap- 
pear only when looking in certain directions, especially upward. In 
this nystagmus which is acquired in later life, a corresponding 
apparent movement of the objects — in a direction opposite to that of 
the ocular movement — is the rule. We may appl}- to this form the 
term motor weakness of the occipital cortex. The wagging of the 
head, which is occasionally present, is explained in like manner as 
cortical motor exhaustion of the centres for the muscles of the neck. 

The nystagmus of multiple sclerosis, tabes, etc., probabl}- develops 
in another way ; in the former disease it is a very characteristic symp- 
tom. Sclerotic foci in the vicinity of the muscle nuclei (hence the 
frequent nuclear paralysis) probably give rise to the disturbance of 
motion. In such foci the nerve fibres are not divided — as happens 
in this disease, according to Uhthoff, in the optic nerve — but merely 
deprived of their medullary layer ; hence conduction is not entirely 
abolished, but merely interfered with. In consequence of this the 
motor cortical impulse to the nuclei of the ocular muscles is more or 
less weakened; there is no complete cortical paralysis but merely 
"paralysis agitans." 

If the theory that nystagmus is due to imperfect innervation is 
correct, it is easily understood that it may occasionally be checked 
by forced conjugate movements (for example, by forced convergence. 



84 THE EYE IN RELATION TO DISEASE. 

V. Graefe) . The notion of a peripheral cause (myopathy) is opposed 
by the circumstance that the movements are conjugate, but periph- 
eral processes may act as predisposing factors. 

Priestley Smith maintained that ocular movements in general have an inter- 
mittent character, and bases this view on the fact that the after- image of the 
sun, during ocular movements, does not form a band but is composed of indi- 
vidual little images of the sun, standing alongside of one another. This is not 
entirely correct. If we look, in the ordinary way, from one point to another 
along the shortest line, then the after-image of the sun is really a band. It is 
only when the eye intentionally changes its direction slowly, that the movement 
becomes discontinuous. This movement is jerky but not oscillating, and leads 
to very rapid optical and motor exhaustion of the eye {vide Landolt, " Beitrag 
z. Physiologie d. Augenbewegungen, " 1892). 

Nystagmus may also be the result of other cerebral diseases 
(subdural hemorrhages, pachymeningitis hsemorrhagica, cerebral 
hemorrhage, cysticercus, etc.), and is often complicated with a corre- 
sponding disorder of vision. In such cases we may also assume an 
incomplete motor paralysis of the occipital cortex. Magelsen 
(Michel's " Jahresber. , " 1883, p. 611) reports an interesting case of 
nystagmus, attended with pains in the back of the head, which 
developed in an overworked seamstress. 

In rare cases rhythmical changes in the size of the pupils (hippus) 
are observed (Michel's "Jahresber.," 1887, p. 511, etc.). 

Cortical spasms of the eye muscles are likewise always conjugate 
and associated. They include tonic and clonic movements to the 
right and left, rolling of the eyes, spasm of convergence, etc. 

Optic and motor fibres are freely intermingled in the occipital 
cortex and its corona radiata, but in the vicinity of the nuclei of the 
ocular muscles the motor fibres are evidently separated from the rest. 
Hence it follows that lesions of the fibres of the corona radiata, 
either in the immediate vicinity of the nuclei or between the indi- 
vidual groups of ganglion cells, may produce purely motor symp- 
toms. These will exhibit a somewhat cortical character and will 
not be attended by degeneration of the nerves and muscles (perinu- 
clear and internuclear disorders of motion). In this way we may 
account for many a so-called paralysis of convergence or imperfect 
fusion of the double images, imperfect conjugate rotation to the 
right or left, etc. This is particularly true of diseases which often 



DISEASES OF THE NERVOUS SYSTEM. 85 

result in circumscribed lesions of the nuclear region, such as multi- 
ple sclerosis, tabes, etc. 

As we have already mentioned on p. 75, a portion of the cortex, 
which is situated in front of the upper extremity of the anterior cen- 
tral convolution (Fig. 8, 1), is definitely related to the levator palpe- 
brse superioris of the opposite side.' Destruction of this centre causes 
crossed paralysis of voluntary raising of the lid. In this centre and 
in that of the facial nerve must also be located the cortical termina- 
tion of the trigeminus nerve. Irritation of this region may cause 
conjugate movements of the eyes to the opposite side. These are 
evidently the voluntary movements of the eyes and lids after con- 
scious sensory stimulation from the lids, conjunctiva, and cornea. 

This explains the well-known fact that ptosis is so often absent 
in central paralysis of the ocular muscles, or that central ptosis may 
be isolated (often associated with central paralysis of the facial 
nerve). The cortical centres are widely separated; the muscle 
nuclei, on the other hand, may be grouped in an entirely different 
manner. 

Experiments on monkeys have shown that mild electrical irrita- 
tion of a definite, circumscribed part of the cortex will produce 
movement of the thumb alone, but more pronounced irritation of the 
same part wiU produce movements of the other fingers, the hand, 
arm, etc. 

The remarkable cases of associated movements of facial muscles 
when the eyelids are widely stretched open may be explained in a 
similar manner. The first two cases of this kind were reported by 
Helfreich (v. Reuss, Wien. kl. Wocli., 1889, N'o. 41). Congenital 
incomplete ptosis was present in almost all the cases. If by an ex- 
tremely vigorous cortical innervation the attempt is made to raise 
the lid, the impulse will be communicated to adjacent parts of the 
cortex, and in this way give rise to both voluntary and involuntary 
movements of other parts. 

Numerous examples of similar processes in other parts of the 

^ Some locate the region in question in the vicinity of the angular gyrus 
(Lemoine, Eev. de Med. , 1887, No. 7) . Others deny, for the present, the possi- 
bility of determining a definite cortical region for "central ptosis." 



86 THE EYE IN RELATION TO DISEASE. 

body could be adduced. [See case of congenital ptosis with synchro- 
nous movements of the affected lid and lower jaw, by Hubbell, 
Archives of Ophth., Knapp and Schweigger, Am. ed., January, 1893, 
p. 63. For other cases see Michel, " Jahresbericht. f. Oph.," 1892, 
p. 354.— iV.] 

3. Transcortical Disorders of Vision. 

It follows, from our previous considerations, that an optical 
as well as a motor projection field must be assumed to exist in the 
visual cortex of the occipital lobe. 

According to Munk the visual cortex of each hemisphere consti- 
tutes a projection field of the opposite half of the field of vision. 
Each part of the field corresponds to a definite part of the cortex, 
and Nothnagel's perceptive centre corresponds to the macula lutea. 

Wilbrand ("Die hemianopischen Gesichtsf eldf ormen, " Wies- 
baden, 1890) has formulated a similar scheme, but describes the 
course of the fibres somewhat more in detail. 

Schaefer holds a different view. According to him the visual 
cortical surfaces of both hemispheres form a single visual field upon 
which both retinal surfaces are projected in approximately the same 
way as if the visual fields of both eyes were drawn upon one field 
(Fig. 1, p. 2). 

On the whole the projection takes place in such a way that right, 
left, above and below in the visual field correspond to left, right, 
posteriorly and anteriorly in the occipital cortex. At the same time 
every part of the cortex may induce a conjugate movement of the 
eyes in such a way that it corresponds to an adjustment of the fixa- 
tion point of both eyes upon the corresponding part of the field of 
vision. 

We cannot, however, represent the matter as if the retina and 
the cortex were simply connected by wires between corresponding 
localities ; the conduction along the wires is transmitted in various 
ways. 

As a result, every point in the visual field, if stimulated with 
sufficient intensity, will stimulate the entire occipital cortex of the 
opposite side, although a certain part of the cortex is stimulated 



DISEASES OF THE NERVOUS SYSTEM. 



87 



most strongly. Furthermore, every part of the occipital cortex will 
innervate all the muscles which rotate the eyes toward the opposite 
side, but the intensity of the stimulus to the different muscles will 
vary with the different parts of the cortex. The stimuli which 
come from all parts of the body keep the muscles in a state of ten- 
sion (tonus). If a stimulus from any part of the field of vision pre- 
dominates, this will furnish an excess of stimulation to the corre- 
sponding part of the cortex, and this in turn induces a corresponding 
conjugate movement. Stimuli which pass to the macular locality 
give rise to convergence and 
accommodation upon the part 
from which the stimulus takes 
its origin. 

Let us assume a stimulus 
is applied to a single retinal 
cone. This will be conveyed 
through the two granular 
layers until it finally stimu- 
lates a number of cells in the 
ganglion - cell layer of the 
retina, one cell most intensely, 
the others less intensely in 
proportion to their remote- 
ness. The centripetal fibres 
of the optic nerve conduct 
these stimuli mainly to the three primary optic ganglia, where the 
fibres, in great part, break up into the neuropilemma. Some of 
the tractus fibres (Fig. 9, T) pass, with or without interruption by 
ganglion cells, to the nuclei of the ocular muscles (k k) — probably 
also to other muscles — and convey the involuntary reflexes which 
follow unconscious impressions of light. This path, viz., optic 
tract — muscle nuclei — motor nerves, n n, we will call the first or 
lowest motor reflex arc. It exists for all senses and groups of mus- 
cles. In adults it plays a subordinate part as regards the eye mus- 
cles, apart from the movements of the pupils. 

In the primary optic ganglia the stimuli which enter are distri- 




FiG. 9.— jT, Optic tract; pO, primary centres of 
the optic nerve; kk, nuclei of the eye muscles; hL, 
posterior longitudinal bundle; nnn, motor nerves 
of the eye muscles; G, Gratiolet's visual fibres; 5", 
visual sphere; R, remaining cerebral cortex; A, as- 
sociation fibres. 



88 THE EYE IN RELATION TO DISEASE. 

buted in the neuropilemma according to the number of conducting 
fibres. The ganglion cells within the neuropilemma will be stimu- 
lated with varying degrees of intensity, according as they are more 
or less remote from the conducting fibres. The stimulation of these 
ganglion cells is conveyed to the cortex of the occipital lobe, in 
which the visual concepts are produced and come to the notice of 
consciousness. As a result voluntary conjugate movements of ad- 
justment are produced in such a way that the image of the object 
in the field of vision falls upon the fovese centrales of both retinse, 
and thence can be conveyed to the perceptive centre with the finest 
possible differentiation. It is only along the tract from the fovea 
centralis to the perceptive centre that visual perceptions can be con- 
veyed of sufficient delicacy to produce optical memory pictures which 
can be utilized. 

These paths — optic tract, primary optic ganglia, corona radiata, 
occipital cortex, corona radiata, muscle nuclei, motor nerves — are 
known as the second or middle motor reflex arc, within which 
voluntary movements follow conscious sensations of light. 

This does not complete the process. By means of associative 
fibres the visual perceptions are : a, combined within the cortex into 
optic concepts and memory pictures ; 6, they are also combined with 
those pictures of the other senses which refer to the same and simi- 
lar objects. These combinations take place particularly with the 
auditory concepts in the auditory centre of the temporal lobe, w^ith 
the tactile and sensory concepts in the so-called motor cortex, with 
the so-called motor soimd pictures in the speech centre (Broca's con- 
volution) and with any existing olfactory and gustatory concepts of 
the object in question. The two latter concepts play a subordinate 
part and may be disregarded. By means of these combinations of 
the various memory pictures the sum of all our knowledge of an 
object, in other words, the concept or idea of the object, is pro- 
duced. 

c. The visual impressions are also conveyed, by means of associa- 
tive fibres, to the frontal cortex. The latter is connected with all 
other parts of the brain by centripetal and centrifugal fibres. For 
this reason the frontal cortex is known to dominate the rest of the 



DISEASES OF THE NERVOUS SYSTEM. 89 

cerebral cortex. In it all conscious percepts are united and from it 
all conscious movements may be incited, modified, and inhibited. 
As is well known this very inhibition of lower reflexes is one of the 
chief physiological functions of higher nervous centres. 

This combination of fibres, viz., a sensory nerve, intermediate 
ganglion (optic ganglia for the optic nerve, optic thalamus for the 
tactile nerves, internal geniculate body and posterior corpora quadri- 
gemina, probably, for the auditory nerve), corona radiata, sensory 
cortical apparatus, associative fibres, frontal cortex, associative 
fibres, motor cortex, corona radiata, muscle nuclei, motor nerves- 
forms our third or highest motor reflex arc, in which perceptions 
that have been thought out are manifested by well-considered move- 
ments or by the inhibition of such movements. Hence the close re- 
lationship between the cortical centre of the most carefully elaborated 
movements and the motor speech centre, which is innervated (inhi- 
bited) from the frontal brain, either spontaneously or as the result of 
sense-perceptions. Speech without the act of speaking is equivalent 
to thought, and in this sense we may apply the term thought-centre 
to the frontal cortex, especially on the left side. As a matter of 
course this function can only be exercised in connection with the re- 
mainder of the cerebral cortex. Hence diseases of the frontal cortex 
do not permit of localization because every portion takes part, in a 
more or less uniform manner, in the functions of all the organs of 
sense and motion. It does not necessarily follow, however, that all 
parts of the frontal cortex are strictly co-ordinate. Indeed, certain 
observations compel us to assume the opposite. But a localization, 
for example, as regards numbers, musical notes, etc., cannot be car- 
ried out because such details depend evidently on the characteristics 
of development. Diseases of the frontal brain are manifested by 
symptoms which vary from mere qualities of character to insanity 
and complete dementia. The local symptoms are either general or 
entirely absent. A sort of local symptom is furnished when an 
ataxic disorder of speech foUows a change of character in progres- 
sive disease of the frontal brain (general paresis). 

In diffuse disease of the cortex hallucinations (sight, hearing, 
feeling, taste, smell), central paralysis and spasms may indicate the 



90 THE EYE IN RELATION TO DISEASE. 

implication of its sensorial and sensori-motor parts. Insanity proper 
is produced only when the frontal cortex and its medullary fibres are 
affected. 

It is evident that the purely anatomical course of the fibres in the 

brain, so far as known at the present time, permits wide inferences, 

* which agree entirely with the results of clinical experience. But 

we will return to the consideration of the transcortical disorders of 

vision. 

If the visual sphere, with its peripheral connections, is intact and 
capable of function, but is cut off from the rest of the cortex, a very 
peculiar condition is produced, which is known as psychic blind- 
ness. Vision is good and the finest objects are seen and fixed, but 
they are not recognized. Recognition takes place at once when the 
object is perceived by another sense, for example, touch. In these 
cases we have the visual sphere sharply isolated from all its connec- 
tions — while sight and the power of fixation are undisturbed. 

It appears, however, that vision may not be perfect in psychic 
blindness ; a disorder of the color sense is also found occasionally 
(Charcot). 

Psychic blindness is only possible under two conditions: 1. The 
causal lesion must not be too extensive. Otherwise local symptoms 
will be present either in the visual sphere itself (homonymous defects 
of its field of vision, conjugate spasm or paralysis) or in neighbor- 
ing parts of the cortex (auditory sphere, motor cortex). Further- 
more the lesion must not extend too deeply into the brain. For this 
reason psychic blindness is almost always a temporary condition 
which either recovers or, if the process is progressive, passes into 
cortical blindness. 

2. The functional isolation of the occipital cortex must either be 
bilateral and hence be due to a symmetrical disturbance (which is 
comparatively rare), or one visual sphere is completely eliminated. 
This gives rise to cortical hemianopsia, and the condition of psychic 
blindness is then found in the intact half of the field of vision. This 
is the more frequent condition. 

Psychic blindness, therefore, exhibits no constant anatomical ap- 
pearances. It is due generally to the remote effects of a lesion situ- 



DISEASES OF THE NERVOUS SYSTEM. 91 

ated in another part of the brain. If, for example, a strip of super- 
ficial softening occurs at the anterior border of one visual sphere 
while the function of the other is abolished (hemianopsia), the 
associative fibres of the occipital cortex may be interrupted during 
the acute initial stage and psychic blindness develops. At a later 
stage the remote action ceases, the psychic blindness disappears, and 
the narrow peripheral band of cortical softening causes no noticeable 
local symptoms or, at the most, a few degrees narrowing of the 
visual field inferiorly. 

Psychic blindness is a local symptom, only in so far as it indi- 
cates that the visual sphere and its peripheral connections are still 
capable of function. It occurs very rarely as an isolated symptom. 

A similar condition in those upon whom the operation for congenital cataract 
has been performed, in imperfect adjustment of the eyes, particularly in mono- 
chromatic light, etc., is sharply distinguished from true psychic blindness by 
the fact that vision in them is either decidedly impaired or that objects do not 
present the same appearance to such persons as they do to others. 

The remaining transcortical disorders of vision are really of an 
aphasic or paraphasic character. Indeed, psychic blindness is a 
speech disturbance, in so far as the distinct sight of an object does not 
call forth its being named because its name cannot be given. 

The motor speech centre is dominated from the first frontal con- 
volution of the left hemisphere (Broca's convolution) and its vicinity. 
Its destruction produces motor aphasia, i.e., the impossibility of 
spontaneous innervation of the larynx and the walls of the buccal 
cavity in the manner necessary to articulate speech. On the other 
hand, the involuntary movements are intact, as in all cortical par- 
alysis. The power of mechanically repeating words after another 
may also remain more or less intact. 

The motor speech cortex is situated, in the main, in the anterior 
and posterior central convolutions and their vicinity. Fig. 10 shows 
the approximate distribution of those cortical regions which are 
chiefly involved in " speech" in the widest sense : M8p, is the cor- 
tical origin of the muscles employed in speech. 

The cortical centre of the right hand, which is especially impor- 
tant in writing, is situated about the middle of the posterior central 



92 



THE EYE IN RELATION TO DISEASE. 



convolution (Fig. 10, MSch). The perceptivec entre for auditory- 
impressions is situated about the middle of the second temporal con- 
volution. The cortical centres of taste and smell, whose location 



MSch 




Fig. 10.— JPi, 5, 3, Frontal convolutions (i^j, Broca's convolution); Tj, 2, first, second, tena- 
poral convolutions; (Ti, Wernicke's convolution, so-called); FC, HC, anterior and posterior 
central convolutions; GSM and Ga, supramarginal and angular gyrus, together— inferior par- 
ietal lobe; Z, cuneus; MSch, motor writing centre; MSp, motor speech centre. 

is still unsettled, may be disregarded on account of their slight im- 
portance in man. 

The acquisition of ideas and concepts begins long before that of 
speech. At first the new-born babe is a simple reflex machine. 
Gradually the central nerve fibres become medullated and thus capa- 
ble of function. At about the age of five months this has taken 
place in the entire white matter of the brain. The ocular move- 
ments, which were at first irregular, are then converted into conju- 
gate and associated movements. Objects are fixed and their move- 
ments are followed. This can usually be done at the age of three 
weeks. Optical impressions of the objects are then obtained and 
are retained as memory pictures. These are combined, with tactile 
and gustatory impressions and pictures of the object, into ideas and 
concepts. Objects are recognized long before the first attempts at 
speech, and this is manifested by voluntary imitative movements. 
Every sensory impression calls up, by means of association, other 
sense-impressions of the object, and then excites movement. 



DISEASES OF THE NERVOUS SYSTEM. 



93 



At first the impressions of sight, feeling, taste, and smell play the 
principal part; auditory impressions are subordinate and rarely 
characteristic. This changes with the acquisition of speech. 

At first conscious auditory impressions are imitated voluntarily 
in a purely mechanical manner. The auditory impressions con- 
veyed from the ear (O, Fig. 11) to the auditory sphere {H} are con- 
ducted by associative fibres to the speech centre (Sp) and are 
imitated by means of movements, which are innervated from that 
centre under the control of the auditory sphere. If an object, 
which is already known to the individual, is often exhibited or is 
felt by the hand at the same time that the name of the object is pro- 
nounced, then the already existing concept will be associated with 
the corresponding sound-picture. The object, when seen or felt, 
recalls the sound-picture and 
the latter recalls the object. 
This constitutes the first step 
in conscious speech, which be- 
comes more perfect and fiuent 
with time. Objects, which 
are seen, heard, felt, etc. , call 
forth in the cerebral cortex, 
by means of association, the 
memory pictures of all other 
senses and, at the same time, 
the motor sound-picture in 
the speech centre, which un- 
dergoes innervation. The ob- 
ject is then recognized and 
called by name. At the same 
time all these parts of the cortex innervate the frontal brain and 
there the perception is brought into relation with the sum of all 
other present and former perceptions. From the frontal brain the 
speech centre is inhibited or innervated in another manner. The 
latter connections are absolutely necessary to rational speech and 
also to spontaneous speech. Hence the great importance of the first 
left frontal convolution, in and beneath which pass all the associa- 




FiG. 11.— Schematic Diag:ram of the Disturbances 
of Speech. O, ear; H, auditory sphere; A, eye; S, 
visual sphere; R, right hand; Sch, writing centre; 
K, muscles of larynx and mouth; Sp, motor speech 
centre; St, frontal brain. The arrow-heads are 
made heavier in proportion to the preponderance of 
the conduction in the directions they indicate. 



94 THE EYE IN RELATION TO DISEASE. 

tive fibres from the frontal brain to the "motor speech cortex" 
proper. 

Speech is under the constant control of hearing. If this is abol- 
ished in the adult (interruption of O H, peripheral deafness), a 
disturbance of speech gradually develops. The voice becomes 
peculiarly hoarse, monotonous, finally almost unintelligible. In con- 
genital deafness speech is not acquired without special instruction. 
If deafness takes place in the first few years of life, the words al- 
ready learned are forgotten. In both instances deaf-mutism develops. 

Deaf-mutes learn to speak by seeing and touching the mouth as it takes the 
required positions for speech, and by seeing the movements of the larynx, and 
these impressions take the place of auditory impressions. Under good instruc- 
tion the individual may learn to speak tolerably well. As a matter of course, 
however, all his notions lack auditory concepts and memory pictures (acoustic 
sound pictures) . 

The paths of rational speech (not the mere repetition of words 
spoken by another) pass through the frontal brain {H — St — >Sp), 
where the sensory impressions and memory pictures of all the senses 
meet, and under whose influence speech is uttered or repressed 
(inhibited). As a matter of course, auditory impressions play the 
most important part. 

If any combination of words is frequently repeated (learned by 
rote), direct connections evidently develop between the auditory 
sphere and the speech centre (H — 8p), and make it possible to 
repeat the combination "without thinking" and without passing 
through the frontal brain. This category includes the multiplica- 
tion table, the names of the days and months, certain songs, pray- 
ers, etc. , which may be repeated in a perfectly mechanical manner. 

The part played in speech by these direct connections is subject 
to great individual variations. They greatly facilitate fluent speech. 
When they are lost, speech becomes labored. Even the most trivial 
and familiar things must then be reconstructed anew, through the 
medium of the frontal brain and the remainder of the cerebral cor- 
tex. To this condition the term dysphasia may be applied, i.e., 
speech is possible, but is attended by such mental strain that it is 
soon abandoned. The condition is similar to that which would be 



DISEASES OF THE NERVOUS SYSTEM. 95 

experienced in solving a complicated mathematical problem if the 
formulae were not known by heart and it became necessary to work 
them out anew, or as if we were compelled to calculate the neces- 
sary logarithms instead of employing the table of logarithms. 

But if the influence of the frontal lobes and the associated sen- 
sory cortex upon the speech centre is abolished, the individual must 
rely solely upon the direct connections between the auditory sphere 
and the speech centre. Much may still be spoken in a mechanical 
manner, words and short sentences may be repeated, and objects 
may be correctly named ; but the control over the sense of the lan- 
guage is lost, as soon as it goes beyond the simplest things. Letters, 
syllables, and words are apt to be omitted or mistaken for similar 
sounds — in brief, paraphasia develops. This is observed with the 
greatest distinctness when diseases of the frontal lobe extend grad- 
ually toward the motor speech centre, particularly in paralytic 
dementia. 

The conditions become more complicated when reading and writ- 
ing are learned. 

Speech is usually developed to a considerable degree when the 
individual begins to learn to read. At first a series of images of the 
letters is committed to memor}^ and each is combined with a definite 
sound picture. At the beginning the reading is done aloud, ^.e., 
the visible "writing-image" (which does not exhibit the slightest 
resemblance to the object which it designates) calls forth the corre- 
sponding sound in the auditory sphere and in the motor centre. 

If a word, composed of several letters, is read, its meaning is 
recognized more rapidly and easily when, by successive enunciation 
of the letters, the sound-image of the entire word is produced, be- 
cause the latter has been made familiar while learning to talk. But 
soon this is no longer necessary. Even without this assistance the 
writing-image of an object directly calls forth the acoustic and motor 
sound-image. This shows the importance of the connection between 
the visual and auditory spheres in learning to read. The predom- 
inant influence of the auditory sphere sometimes continues through 
life. But if reading is practised very extensively, direct connections 
of the visual sphere gradually develop and render unnecessary the 



96 THE EYE IN RELATION TO DISEASE. 

deflection on the one side to the motor cortex, and on the other side 
to the frontal cortex. Reading thus becomes more and more inde- 
pendent of the auditory sphere and the acoustic sound-images. It 
depends upon circumstances whether one path or another is mainly 
utilized in adalts. Hence, as clinical experience proves, the symp- 
toms will vary greatly in any individual according as one path or 
another is obstructed. 

When reading aloud is practised extensively, direct paths develop 
in particular between the visual sphere and the motor speech centre, 
so that finally the act of reading becomes purely mechanical. If the 
individual reads much to himself, special direct connections with 
the frontal lobes are gradually developed. Finally, the concepts of 
objects and processes may be called forth as readily or even more 

readily, by writing-images 
as by the sound-pictures of 
the auditory sphere. (A 
written article can then be 
read and understood by the 
individual much more rap- 
idly than when the article 
is read to him.) The man- 
ner of education, etc., are 
the main factors in the pro- 
'o ^^ duction of these individual 

F.O. i2.-comp. Fig. n, p. 93. differences. 

Similar processes take place in learning to write. Originally the 
script-images are imitated mechanically, and this is evidently done 
by connections between the left visual sphere and the cortical centre 
for the right hand, situated in the left central convolutions {S — 
Sch, Fig. 12). In learning to write, speech is first employed to 
pave the way for a comprehension of what has been written ; S — H 
are innervated synchronously with S — Sch^ and the sound-pictures 
are aroused in the auditory sphere. In fluent writing the former 
path is abandoned more and more, and the direct tracts S — Sch, are 
perfected, especially if copying is extensively practised. But if the 
individual writes mainly from dictation, the direct connections 




DISEASES OF THE NERVOUS SYSTEM. 97 

H — Sch, will be chiefly developed. In adults, accordingly, the 
different tracts may vary greatly in importance. If the writing is 
done with thought, the frontal brain is innervated at the same time 
and controls the act of writing. The oftener the writing is done 
from dictation, the oftener the frontal lobes are avoided, and the 
more mechanical does the process become. 

On account of learning to write with the right hand the predom- 
inance of the left hemisphere in all forms of speech becomes perma- 
nent. If the left hand is used in writing (in left-handed individu- 
als), this predominance is transferred to the right hemisphere. 
We will not discuss the question whether the ordinary right-handed- 
ness is the result of a congenital predominance of the left side or 
whether the latter is the effect of education. At all events speech, 
with all its complicated relations, appears to be so difficult that it can 
be learned thoroughly only by a single hemisphere. In adults the 
loss of the speech centre cannot be completely repaired, but as late 
as the age of seventeen years, the loss of the right arm may induce 
a transfer of the speech centre to the right hemisphere. 

The following brief resume indicates the tracts in which the 
different speech functions run their course {vide Fig. 12) : 

1. Speaking: 

a, is originally learned in a purely mechanical manner: 

O— H— Sp— K, 
6, is spoken understandingly in conversation : 

O— H— St^— Sp— K, 
c, is spoken spontaneously : 

St— Sp— K. 

2. Reading : 

a, reading aloud in a purely mechanical manner : 

A— S— H— Sp— K, 
&, reading aloud, understandingl}', at first : 
A-S— H— St— Sp-K, 
later : 

A— S— St-Sp— K, 

' St indicates not alone the frontal brain but also the associated sensorial and 
sensory cortical regions. 



98 THE EYE IN RELATION TO DISEASE. 

c, reading softly, understandingly, at first : 

A— S— H— St— Sp!/ 
later : 

A— S— St-Sp!, 

d, frequently practised reading : 

A— S-Sp— K. 
3. Writing : 

a, purely mechanical writing of the alphabet : 
A— S— Sch— E, 
then the letters pronounced at the same time ; 
I Sch-R, 
^ ^JH-Sp-K, 
5, copying understandingly, at first : 

A— S— H— St— Sch— R, 
later : 

A— S— St— Sch— R, 
finally in a more mechanical manner : 
A— S— Sch— R, 
but more perfectly than in the beginning, 

c, writing from dictation, at first : 

O— H— St— Sch— R, 
later, more mechanically : 

O— H— Sch— R, 

d, writing voluntarily: 

St— Sch— R. 

As a matter of fact, however, the conditions are much more com- 
plicated {vide Malachowski, Volkmann's "Klin. Vortr.," IN'o. 224; 
Wysmann, Deutsch. Arch. f. kl. Med., 47, p. 27) because it has 
been found clinically that the ability to speak, write, and read may 
be lost only in part. For example, the knowledge of numbers and 
the ability to count may be lost; indeed the individual may even be 
able to reckon with numbers up to three, while the higher numbers 
are lost. The knowledge of musical notes may be lost or the ability 
to sing, and this may even be restricted to certain notes and tones. 
Or an acquired language alone is lost while the speech faculty other- 

' ! indicates an inhibitory action. 



DISEASES OF THE NERVOUS SYSTEM. 99 

wise remains intact ; or certain groups of words, such as nouns, or 
even individual words and letters, may alone be lost. In short, the 
clinical symptoms may exhibit the greatest possible variations. 

In the central disorders of speech {vide I^aunyn, Congress f. 
innere Medicin, Wiesbaden, 1887) there are two principal groups, 
viz., motor and sensory aphasia (Wernicke). In pure motor 
aphasia (also called ataxic in contrast to anarthric aphasia, which 
is due to paralysis and weakness of the speech muscles) it is impos- 
sible for the patient to utter the word, which is on the tip of his 
tongue, although he recogTiizes it when spoken and read and also 
the corresponding object.' This affection is located in the left infe- 
rior frontal convolution, the destruction of which interferes with the 
connection between the left frontal lobe and the motor centre of the 
speech muscles in the lower third of the anterior central convolu- 
tion. This variety contrasts somewhat with amnesic aphasia (Ogle, 
Bastian) in which the "internal" word is forgotten, i.e., the motor 
tone-picture. 

A mild grade of ataxic aphasia is known as paraphasia (also 
called conduction aphasia) in which letters, syllables, and words are 
omitted or are confused with others which have a similar sound. 
Here conduction is not interrupted, but is merely interfered with or 
there is irregular innervation. 

As in all other central muscular disorders the involuntary move- 
ments (deglutition, respiration, etc.) are entirely intact. 

In sensory aphasia we ma^^ distinguish, in general, two groups, 
according as the relations of hearing or sight to speech are disturbed. 
On account of the greater importance of the sense of hearing in 
speech, acoustic aphasia or aphasia with word- deaf ness is the more 
frequent. Despite the patient's ability to hear, the comprehension 
of spoken words and sounds is disturbed in this affection. It is 
located in the upper part of the first temporal convolution (Wer- 
nicke's convolution), beneath which the connections of the auditory 
sphere (Fig. 10) are situated anteriorly. 

There have been very few accurate reports of cases of optic aphasia 
(aphasia with word-blindness) in which, despite the ability to see, 
there is lack of comprehension of visible objects and words {vide 



100 THE EYE IN RELATION TO DISEASE. 

Freund, Arch. f. Psych., XX, p. 387). In Sigaud's case (Frog. 
Med., 1887, No. 36) there was found, for example, a spot of soften- 
ing, as large as a walnut, in the left inferior parietal convolution 
(Fig. 10, Ga and Gsm), i.e., in a place where the association fibres 
of the visual sphere must run forward. Other cortical disorders of 
vision, particularly hemianopsia, are very often combined with 
word-blindness. It has often been found that the disease was situ- 
ated in the right hemisphere, even in right-handed individuals. 
We have already emphasized the fact that such interruptions of con- 
duction are necessarily bilateral, and are therefore more apt to occur 
when the function of one visual sphere has already been abolished, 
i.e., when hemianopsia is present. A lesion on the right side which 
has caused left homonymous hemianopsia will, therefore, be more 
apt to produce, by "remote effect," a condition of word-blindness or 
interruption of conduction in the associative fibres of the other 
visual sphere which run anteriorly. 

There are also a number of " undefined" forms of aphasia which 
are located in the vicinity of the three important cortical speech 
centres. According to Grashey aphasia may also be produced by 
a simple diminution of the duration of sensory impressions, although 
the tracts or centres in the brain are not destroyed. 

It is certain that the sensory disorders of speech develop when 
the connection of the auditory or visual sphere, or both, with the 
anterior parts of the brain is abolished or interfered with. As Fig. 
10 shows, the disorder will be purely or chiefly acoustic when the 
disturbance of conduction is located beneath the first temporal con- 
volution, and chiefly optical when it is located in the inferior parie- 
tal convolution (supramarginal and angular gyri). The same 
figure also shows that tracts whose functions differ widely may be 
affected in places which are closely approximated. 

We have seen (p. 59) that unilateral destruction of Nothnagel's 
perceptive centre produces crossed homonymous hemianopsia, and 
bilateral destruction results in cortical blindness. In this locality 
optical impressions mainly undergo associative connection with one 
another. The more they are situated toward the periphery of the 
visual sphere, the more the optical impressions are combined with 



DISEASES OF THE NERVOUS SYSTEM. 101 

those of the other senses. To all parts of the visual sphere which 
are situated outside of its perceptive centre Nothnagel applies the 
term "memory centre for visual impressions." If a considerable 
part of this is destroyed, a part of the optical images already known 
lose their association with the memory pictures of the other senses. 
The optical image does not recall to memory the object and its name 
(partial psychic blindness). If the perceptive centre has remained 
intact, new memory pictures may be acquired, and so much more 
easily the younger the individual. This locality alone receives 
from the macular portion of the retina visual impressions which 
are sufficiently detailed to be employed in the production of optical 
memory pictures. It is also easy to understand the fact that in 
optical aphasia concrete nouns are especially concerned. These alone 
possess real optical memory pictures. The optical memory picture 
of a verb or of an abstract noun is merel}^ a writing-image. 

After these preliminary observations w^e will briefly mention the 
more important clinical forms of optical disorders of speech. In the 
nature of the case these are chiefly disorders of reading and writing. 

Word- Blindness. — Despite perfect vision the names of objects 
cannot be recalled, although they are recognized. This fact distin- 
guishes the condition from psj^chic blindness in which the objects 
are not recognized. In word- blindness proper {cecite verbale) 
printed or written words cannot be spoken ; in other cases the writ- 
ing-image of a word recalls its tone-image to memory and it can 
then be correctly spoken (optical word amnesia, amnesie verbcde 
visuelle) . In the main such cases result from considerable loss of 
the peripheral parts of the visual sphere, together with abolition of 
the association between the visual and auditory spheres, each of 
which remains intact. In word-blindness proper there is also loss 
of association between the visual spheres and the motor speech centre. 

Optical aphasict can only be distinguished from word-blindness 
by regarding the former as motor aphasia plus w^ord-blindness. 

Alexia is the inability to understand w^riting or print, or both, 
although the characters are seen and can be reproduced, and the 
words themselves are recognized and can be uttered (optical alexia). 
Or written and printed matter is understood but cannot be read aloud 



102 THE EYE IN RELATION TO DISEASE. 

(motor alexia) , although the words, when spoken, can be repeated by 
the patient. In optical alexia the memory pictures of the signs of 
writing and words are lost, probably in the peripheral parts of the 
visual sphere. In motor alexia they are retained, but their associa- 
tion with the motor speech centre (probably also with the auditory 
sphere) is interrupted. 

Dyslexia is the term applied by Berlin (" Ueb. eine besondere Art 
d. Wortblindheit, " Wiesbaden, 1887) to a condition in which the 
patient could read but, after uttering a few words, a peculiar uncom- 
fortable feeling was produced and compelled him to stop. It is a 
notable fact that this condition was temporary in all cases. The 
disorder of reading usually ran a favorable course, but severe cerebral 
symptoms developed at a later period. Definite localization was im- 
possible because the disorder must always be a remote effect. It is 
due to impeded conduction between the speech centre and the centres 
of special sense. Later publications on dyslexia coincide in the main 
with Berlin's statements. It is possible that the principal part in 
this disorder is played by obstructed cortical "oculomotor" innerva- 
tion of the left occipital cortex on moving the eyes toward the right 
side {vide page 78) . 

Paralexia is a term (analogous to paraphasia) applied to a con- 
dition in which single letters, syllables, or words are omitted in read- 
ing, or are confused with others, especially those which have a 
similar sound. 

Agraphia is the inability to write, although the movements of 
the hand and arm in other respects are approximately normal. We 
may distinguish a motor form (probably due to destruction or com- 
plete isolation of those parts of the cortex from which the right hand 
is innervated in writing) and a sensory form (in which conduction 
is interrupted between the last-named centre and the visual and audi- 
tory centres). The latter form maybe subdivided into two varieties. 
In one variety, the patient cannot copy but can write on dictation or 
when the words are at the same time read aloud (optical agraphia). 
In acoustic agraphia the individual can copy but cannot write on 
dictation. The loss of both these functions at the same time would 
be tantamount to sensory agraphia. 



DISEASES OF THE NERVOUS SYSTEM. 103 

Paragraphia is the confusion or omission of letters, syllables, 
and words in writing. This may only be jjresent or predominate in 
spontaneous writing, in copj^ng, or in writing from dictation. 

All these disorders of speech may easily be made schematic {vide 
Wysmann, I.e.). In reality, however, there are numerous transi- 
tions and combinations; pure forms are very rare and are almost 
always temporary, either ending in recovery or passing into more 
severe forms. 

Interesting as it is to analyze the process of speech, all these dif- 
ferent forms of disease permit only a very limited local diagnosis 
with regard to interference with or interruption of conduction be- 
tween different parts of the cerebral cortex. If the motor factor pre- 
dominates in a speech disorder, the interruption is to be looked for 
near the motor centres ; if the acoustic or optic factor predominates, 
it is to be looked for nearer to the corresponding part of the cortex. 

Together with the disturbance of conduction there is more or less 
disturbance or loss of the optical, acoustic, and motor memory- 
pictures of speech, which are situated at the periphery of the corre- 
sponding motor or sensorj^ parts of the* cortex. If the latter disturb- 
ance exceeds that of conduction, the speech disorder assumes an 
amnesic character. 

In order to make a thorough examination of a central disorder of 
speech we must note : 

1. Whether the individual can speak and write spontaneously 
and rationally, /.e., whether speech is normally influenced by the 
frontal brain. If the latter is extensively diseased, thought, speech, 
and writing are irrational (insanity) . Paraphasia and paragraphia 
are apt to develop when the frontal brain functionates but does not 
influence speaking and writing in a normal manner, either on ac- 
count of irregularities of conduction (progressive paresis) or even in 
the normal individual who reads and writes mechanically, while 
absent-minded. If Broca's convolution is destroyed, spontaneous 
and rational speech is impossible, but mechanical repetition is still 
possible. Even this is no longer possible when the cortical origin of 
"the nerves of speech" (Fig. 10, MSp) is destroyed (typical motor 
aphasia). 



104 THE EYE IN RELATION TO DISEASE. 

2. Whether acoustic disorders are present, i.e., whether the in- 
dividual can repeat or write dictated words. In pure motor aphasia 
spoken words and sentences are understood ; they are not understood 
if word-deafness is also present. If the latter exists alone, the in- 
dividual can speak voluntarily and can read writing aloud, but he 
cannot repeat or write what he hears. If, at the same time, letters, 
syllables, or words are omitted or confused with others, especially 
with those of similar sound, the condition may be called acoustic 
paraphasia. 

3. Whether optical disorders are present, i.e., how objects shown 
to the individual are called or their names written, and how written 
and printed matter is read aloud or copied. In word -blindness ob- 
jects are not recognized; in writing-blindness written or printed 
objects are not recognized, although they are seen with perfect dis- 
tinctness and their names can be repeated. We should examine 
whether and how objects shown are named, and written and printed 
matter is read or copied. At the same time it should be noted 
whether letters, syllables, and words are omitted or mistaken, as 
this merely indicates irregularity of conduction. 

Educated patients are to be examined in the same way, and also 
in regard to musical ability, foreign languages, mathematical knowl- 
edge, etc. This may render the examination very complicated, but 
will furnish no further diagnostic data with regard to more accurate 
localization. 

In conclusion, a few words with regard to 

4. The Frontal Brain. 

In regarding this part of the brain as superior to the remainder of 
the cerebral cortex we are opposed to the majority of writers, who 
consider such a higher " centre" unnecessary and superfluous. We 
are forced to this conclusion, however, by the teachings of anatomy, 
inasmuch as the frontal cortex receives fibres from and sends fibres 
to all other parts of the cortex. The chief functions of the frontal 
cortex are assumed to be : 

1. Inhibition of voluntary movements following conscious sensory 
impressions, or the execution of deliberative movements with coin- 



DISEASES OF THE NERVOUS SYSTEM. 



105 



cident consideration of all sensory impressions, including those which 
are remembered as well as present impressions. 

2. The execution of spontaneous movements, likewise upon the 
basis of all past and present sensory impressions of all the senses. 

As a matter of course the frontal lobes do not perform these func- 
tions "detached from all other parts of the cortex," but in association 
with them. 

In view of the great importance of language, which distinguishes 
man from the lower animals, the most important function of the 




vOP 



Fig. 13.— Normal Human Brain, after a figure from Wernicke, the frontal brain limited by 
a dotted line. Lettering as in Fig. 14; in addition: CF^ calcarine fossa; wOjP, inferior oc- 
cipital sulcus; Z, cuneus; Pc^ prsecuneus; Ga, angular gyrus; Gs?n, supramarginal gyrus; VC 
and IZC, anterior and posterior central convolutions. 



frontal lobes consists in their relations to speech. This is manifested 
by the close proximity of the corresponding parts of the cortex. The 
more the frontal brain approaches the cortical centre for the speech 
muscles (Fig. 10, MSp) the more it assumes the role of a motor 
organ superior to the latter. The chief difference between the brain 
of monkeys and of man consists in the much more pronounced de- 
velopment of the frontal lobes in the latter {vide Figs. 13 and 14). 

We have seen that no part of the cortex is purely motor or purely 
sensory, but that it exercises both functions, z.e., it receives and sends 
out stimuli, although these vary qualitatively and quantitatively in 
different places. Nevertheless, the individual regions of the cortex 



106 



THE EYE IN RELATION TO DISEASE. 



possess characteristic functions so that localization is possible. This 
is not true of the frontal lobes. Here every part evidently receives 
stimuli from all the sensory organs and can send stimuli to all motor 
cortical regions. Although from a purely theoretical standpoint not 
all parts of the frontal cortex can be co-ordinate in the strictest sense 
of the word, yet a local diagnosis is not possible. The greatest pos- 
sible subjective differences will be present in different individuals, 
as a result of the character of the education. 

Hence, affections of the frontal cortex, which are not too slight 




Fia. 14.— Brain of Monkey, after a figure from Horsley and Schafer; the dotted line sepa- 
rates the motor region from the frontal brain. FS, Fossa of Sylvius; PcF, precentral fissure; 
CF, central fissure; JF, interparietal fissure; PoF, parieto-occipital fissure; PaF, parallel 
fissure. 



in extent, will not be manifested by disturbances of individual sensory 
organs or groups of muscles, but by changes in the general impression 
produced by the outer world, by changes in thought and voluntary 
action, ^.e., by changes of character. 

Diseases of the frontal cortex, especially those of a diffuse char- 
acter, may be called mental diseases, although not every circum- 
scribed and slowly progressive lesion (tumor or abscess) in this re- 
gion necessarily produces a typical form of insanity. Such diseases 
may run their course without noticeable or characteristic symptoms, 
on account of the relatively co-ordinate value of all parts of the 



DISEASES OF THE NERVOUS SYSTEM. 107 

frontal brain and the possibility that the different parts may act 
vicariously for one another. 

Extensive surface disease of the frontal cortex will always be 
manifest as a mental affection (in the broadest sense of the word) 
and irritative symptoms (hallucinations) will be present or absent 
according to the implication of sensorial and sensory regions of the 
cortex. To this extent the presence and absence of hallucinations 
may be properly employed as a principle of classification in insanity. 

It is plausible to attribute maniacal conditions to diffuse arterial 
hypersemia and increased irritability, and melancholic conditions to 
passive hypersemia, but for the present such assumptions are purely 
hypothetical. 

I would suggest, however, that when anaemia, hypersemia, or 
both are present in patches in the frontal cortex, increased and 
diminished or even normal excitability will be found coexisting. 
The result must be a complete confusion both as regards centripetal 
sensory impressions and motor manifestations. 

5. Disorders in the Domain of the Sensory Nerves. 

Peripheral irritation of the sensory nerves will result in neu- 
ralgias; peripheral paral^'sis will result in anaesthesia of the corre- 
sponding branches, and contact or irritation will then fail to produce 
reflex movements. Peripheral anaesthesia of the cornea — whether the 
trigeminus is affected in the orbit, the base of the skull, in the 
Gasserian ganglion, or between the latter and its origin in the brain 
— often leads to so-called neuro-paralytic keratitis. This may recover 
at any stage, but is usually followed by loss of the eye. Without 
entering further into the clinical relations of this disease or into the 
question of the existence of trophic nerves, it may be remarked that 
we evidently have to deal with a traumatic loss of substance (this 
is very apt to occur on account of the insensibility of the cornea) 
which is infected from the conjunctival sac. The further course 
of this condition is modified by the fact that the vascular reflexes in 
the remote conjunctival, scleral, and episcleral vessels, which are 
necessary to the healing of an infected ulcer, remain absent. Hence 
there is no reaction of the tissues and the process makes a charac- 



108 THE EYE IN RELATION TO DISEASE. 

teristic, steady progress. The assumption of special trophic nerves 
is superfluous. 

In hysterical anaesthesia of the cornea neuro-paralytic keratitis is 
never observed, because the involuntary vascular reflexes are intact, 
and are often exaggerated. The nerve fibres are not interrupted or 
destroyed, although the sensory irritants do not enter consciousness. 

We can only entertain surmises concerning the central course of 
sensory trigeminal stimuli. With the exception of those roots v^hich 
pass to the cerebellum and the spinal cord, the remainder — such as 
the ascending sensory spinal fibres of the tegmentum — probably 
pass, in the main, to the great centre of involuntary mimicry, the 
optic thalamus, and there terminate in the network of nerve fibres. 
The ganglion cells of the thalamus send their axis cylinders to 
the cortex of the parietal lobe, the so-called motor, preferably motor- 
sensory cortex (Monakov^) . We v^ill hardly go astray in assuming 
that the cortical termination of the trigeminal fibres of the eye, 
which are interrupted in the thalamus, is that part of the " motor" 
cortex which presides over the movements of the ocular muscles 
(Fig. 8, 1). 

A lesion of this part in man appears to produce central paralysis 
of the opposite levator palpebree superioris, the only positively dem- 
onstrated central paralysis of a single ocular muscle. This part of 
the cortex may be regarded as the locality from which voluntary 
movements of the eyelids are executed after conscious stimuli on the 
part of the sensory nerves of the eye. 

Movements of the eyes — conjugate movements toward the opposite 
side — may also be produced by irritation of this locality (Ferrier, 
Beevor and Horsley). Mott and Schaefer {Brain, February, 1890) 
succeeded in making a still more minute differentiation. According 
to them irritation of the uppermost part caused conjugate deviation 
outward and downward ; in irritation of the middle portion purely 
lateral deflection followed, and irritation of the lower portion caused 
conjugate deviation outward and upward. The irritation evidently 
passes along those tracts in which voluntary (always conjugate) 
movements of the eyes follow conscious sensory stimulation of the 
cornea, conjunctiva and eyelids. 



DISEASES OF THE NERVOUS SYSTEM. 109 

These movements probably do not pass, by associative fibres, to 
the visual sphere on the same side, because they remain intact after 
destruction of the occipital cortex. They pass directly through the 
corona radiata to the nuclei of the ocular muscles. The remarks 
made on page 80, concerning cortical conjugate movements of the 
eyes, also hold good with regard to these movements. They are 
always incomplete, and occur approximately in a certain direction. 
Delicate voluntary movements of adjustment can only be innervated 
from the visual sphere under the control of vision. 

The long-known fact that, in cerebral paralyses of the ocular mus- 
cles, the levator palpebras superioris often is not affected, or that it 
is paralyzed alone, perhaps together with the ocular facial, is easily 
explained. It is unnecessary to assume that the nuclei of the levator 
palpebrse and the ocular facial nerve are situated in close proximity 
(Mendel, Siemerling). It is sufficient that their cortical origins 
are closelj" related, and that the chief paths of innervation from the 
motor cortex to the nuclei of the corresponding nerves run along- 
side of one another for a considerable distance. 

6. Disorders of the Involuntary Muscles of the Eye and 
OF THE Sympathetic. 

The muscles in question are the sphincter of the pupil and the 
ciliarj' muscle (whose nerve fibres pass through the motor oculi and 
evidently originate in the groups of small ganglion cells at the 
anterior extremity of the motor oculi nucleus, vide Fig. 6, 1 and 
3) and the dilator pupillse which is supplied by the sympathetic. 
In addition there are radiating smooth fibres in the eyelids, whose 
contraction causes moderate dilatation of the palpebral fissure, and 
the so-called Mueller's muscle, which closes the inferior orbital fissure 
and whose contraction pushes the e3'eball forward (exophthalmus) . 
The two latter muscles are also supplied by the sympathetic, and 
their nerve supply may be followed experimentally to the sixth and 
seventh cervical and the first dorsal segment of the spinal cord, the 
so-called cilio-spinal centre (Budge) . 

Very little will be said here concerning the muscle of accommo- 
dation. Its nucleus, situated close to that median motor oculi 



110 THE EYE IN RELATION TO DISEASE. 

nucleus (Fig. 6,3), which we regard as the centre of convergence, 
appears to be voluntarily innervated, together with convergence, 
from the perceptive centre of the visual sphere, and is under the con- 
trol of conscious vision. There appears to be no direct influence of 
the cerebral cortex upon the pupillary sphincter. It cannot be stim- 
ulated voluntarily, apart from the associated movement in accommo- 
dation and convergence, which is, at least in part, a purely mechan- 
ical process. 

Mention may here be made of Haab's cortical reflex of the pupil. 
Haab found that, independently of any noticeable change in con- 
vergence and accommodation, contraction of both pupils takes place 
when the attention is directed upon a bright object which has already 
been present within the field of vision. The brighter the object, the 
more marked is the contraction of the pupils. Haab assumes very 
properly that this reflex must be cortical in character because it fol- 
lows a purely psychical process. 

It is evident that in this form of attention there is a general inner- 
vation of the cortex of the visual spheres, probably from one of the 
highest centres, i. e. , the frontal lobes. The motor impulse which fol- 
lows such innervation is distributed to all the ocular muscles and is 
therefore noticeable only in those which have no antagonists that 
can be influenced by the will. This is true of the sphincter pupillee. 
It is probable that a coincident accommodation impulse can also be 
demonstrated. It is an interesting fact that the strength of this 
reflex depends upon the brightness of the object. 

The occurrence of the reflex presupposes that the network 
of the motor corona radiata in the motor oculi nucleus and the gan- 
glion cells of the nucleus of the sphincter are intact. The cells or 
fibres of the accommodation nucleus may be incapable of function, 
and Haab reports two cases in which the reflex was retained despite 
paralysis of accommodation. The reflex will be lost if the inter- 
nuclear fibres between the nuclei of the ciliary muscle and pupillary 
sphincter are destroyed, even though both nuclei are intact. In such 
a case accommodation and the involuntary light reflex of the pupil 
may be normal, and this has also been observed by Haab. 

A cerebral influence on the pupil, possibly in an indirect manner. 



DISEASES OF THE NERVOUS SYSTEM. 



Ill 



may also be exerted through the sympathetic. The loss of an entire 
cerebral hemisphere often produces symptoms of paralysis of the 
sympathetic upon the same side of the face, ^.e., upon the side oppo- 
site to the general paralysis. The mydriasis which so often in 
cerebral hemorrhage is upon the side of the lesion, may be the result 
of paralysis of the motor oculi, of irritation of the sympathetic, or 
of both. 

For the sake of convenience the anomalies of the movements of 
the pupils, due to disorders of the motor oculi or of the sympathetic, 
will be discussed together. 

Apart from exceptional cases, such as great differences in refrac- 
tion, etc., the pupils are normally equal in size, and contract to an 
equal amount upon the entrance of light 
into either eye (consensual pupillary 
reaction), and during convergence and 
accommodation. The pupils dilate upon 
irritating the integument in the vicinity 
of the eye. Consensual pupillary reac- 
tion is absent in animals whose optic 
nerves undergo total decussation. 

The light reflex — contraction on the 
entrance of light, dilatation upon cover- 
ing the eye — is a function of the motor 
oculi, resulting from light stimuli which 
are conveyed from each retina through 
the optic nerve, chiasm and tractus to 
the primary optic centres of both hemi- 
spheres and thence to the bilateral nuclei 
of the sphincter pupillse. The disorders 
of this reflex may be, a, centripetal (sen- 
sory visual disorder), h, centrifugal (motor), and c, central (located 
between the primar}' optic ganglia and the muscle nuclei) . 

a. The centripetal pupillary disorders between the eye and the 
primary optic ganglia are at the same time visual disorders and 
hence are bilateral, inasmuch as the optic fibres pass from each eye 
to both halves of the brain. From the blind parts of the field of 




r*0 



Fig. 15.— Schematic Diagram of the 
Movements of the Pupils. R, right, 
i, left eye; Ch, chiasm; pO^ primary- 
ganglia of the optic nerve ; 3/0, macu- 
lar region of the occipital cortex; 
Sp/i, Ace, Conv, nuclei for sphincter 
pupillae. accommodation and conver- 
gence; Oc, oculomotor nerve; gc, cili- 
ary ganglion. 



113 THE EYE IN RELATION TO DISEASE. 

vision no light reaction of the pupils can be produced in either eye, 
from the normal parts the reaction is always equal in both eyes. 
Hence the pupils are equal in size in unilateral disorders of vision, 
unless this is prevented by complications. 

The reaction of both pupils is lost, after the destruction of one 
optic nerve, when the light falls upon the blind eye, and is retained 
and equal when the light enters the sound eye. Jessop's two cases, 
of double blindness with atrophy of the optic nerves and intact reac- 
tion of the pupils to light, have been discussed on page 66. 

In destruction of one tractus or the primary optic ganglia of one 
side there is hemiopic reaction of the pupils, corresponding to the 
hemianopic disorder of vision. Neither pupil reacts from the blind 
half of the field of vision, and both pupils react equally from the in- 
tact half. 

[It may perhaps be well to remark that the existence of the hemi- 
opic pupillary inaction has more value as indicating a lesion at or 
peripheral to the middle optic ganglia, than the non-existence of 
the symptom possesses as indicating a lesion higher up in the cere- 
brum. The former is positive as evidence and, as the editor's ex- 
perience has shown, can be safely relied upon ; the latter is negative 
and of course has less logical value. We may have a partial im- 
pairment of the pupil-controlling fibres and would be led into error 
should we assume that the absence of the hemiopic pupillary inaction 
excludes the possibility of the lesion being one whose effect is either 
peripheral or at the ganglia. It is also conceivable that a tumor 
dorsad to the middle ganglia and perhaps at some distance may by 
indirection effect the lesion, either by pressure or by interrupting the 
fibres.— Ed.] 

If the visual disorder has a more central location, the reaction of 
the pupils to light is not disturbed, although no impressions of light 
enter consciousness. In all these centripetal pupillary disturbances, 
the reaction of the pupils to accommodation, convergence, and cutane- 
ous irritants is retained. 

b. Centrifugal pupillary disorders are unilateral, unless the causal 
affection is situated on both sides. In unilateral paralysis of the 
pupillary sphincter — whether the cause is intraocular (atropine poi- 



DISEASES OF THE NERVOUS SYSTEM. 113 

soning, trauma) , orbital, basal, or nuclear — the pupil of the paralyzed 
eye does not react despite the perfect perception of light, whether the 
light enters one eye or the other. In both cases the pupil of the 
healthy eye reacts properly (complete and partial paralysis of the 
motor oculi). In centrifugal pupiUary disorders the reaction to con- 
vergence and accommodation is likewise 'disturbed in many cases, 
and this always takes place when the muscle of accommodation is 
also paralyzed. At the moment of contraction of this muscle the 
blood of the ciliary body is forced, at least in part, into the iris, and 
this causes temporary contraction of the pupil. Hence, if the ciliary 
muscle is still acting, the contraction of the pupil, although consider- 
ably diminished, is not entirely abolished in vigorous accommoda- 
tion and in convergence, which is always associated with an accom- 
modation impulse. The dilatation of the pupil after cutaneous irri- 
tation is also present in paralysis of the motor oculi, because it is 
effected through the sympathetic. 

c. Central pupillary disorders are those in which the connection 
between the primary optic ganglia (anterior corpora quadrigemina, 
external geniculate body) and the nucleus of the sphincter pupiUae is 
disturbed or iuterrupted, but both remain capable of function. Un- 
less complications are present, there is no interference with conscious 
vision and no paralj'sis of any voluntary movements; the pupillary 
reaction in accommodation and convergence may also be intact. 
There is no reaction of the pupil, however, on the entrance of light 
(reflex rigidity of the pupil). If the interruption or interference 
with conduction is unilateral, illumination of the opposite halves of 
the fields of vision of both eyes causes no reaction of either pupil ; on 
illumination of the corresponding halves of the field of vision the 
pupillary reaction takes place and in both eyes (hemiopic rigidity 
of the pupils). Inasmuch as both pupils are equal in size and react 
uniformly upon the entrance of light, the condition will remain un- 
discovered unless it is looked for, especially as vision is not neces- 
sarily disturbed. Indeed, no case of pure hemiopic reaction of the 
pupils without disturbance of vision has yet been reported, although 
it is probable that this symptom is not very rare. But if conduction 

is interrupted on both sides between the primary optic centres and 
8 



114 THE EYE IN RELATION TO DISEASE. 

the nucleus of the sphincter, reflex rigidity of the pupil (Argyll-Rob- 
ertson symptom) is of frequent occurrence in certain diseases (espe- 
cially tabes dorsalis) which are to be located in the vicinity of the 
motor oculi nucleus {Arch. f. Psych., XXIII, 3). In a case of uni- 
lateral congenital ptosis, Siemerling found bilateral changes in the 
terminal network of the motor oculi nucleus, whose ganglion cells 
were relatively intact. This would explain the reflex rigidity of the 
pupil, which was also present in the case ; but it could not possibly 
have been the cause of the unilateral ptosis. 

In reflex rigidity of the pupils we would expect them to be larger 
than normal, because the light no longer exerts a contracting influ- 
ence. In reality, however, this does not often happen. The pupils 
are usually narrowed to a considerable extent (myosis) . It appears 
as if in destruction of the fibres which break up into a terminal net- 
work in the sphincter nucleus, a constant irritation is exercised upon 
the ganglion cells lying within the network. This view is corrobo- 
rated by Uhthoff's case {Berl. kl. Woch., 1886, 3 and 4) in which 
slight pupillary contractions were constantly occurring during reflex 
rigidity of the pupil. As this irritation is not necessarily equal on 
the two sides, the pupils may vary greatly in size. Cocaine dilates 
the rigid pupil by stimulating the sympathetic. 

Difference in the size of the pupils without any local cause in the 
eye (inflammation, etc.), and without pronounced diminution in their 
mobility, is a symptom which points to the region between the primary 
optic ganglia and the motor oculi nucleus. The condition may be of 
the nature of an irritation or a beginning paralysis. 

When the pupils differ in size (anisocoria) it is often difficult to 
decide whether one is too large or the other too small. In doubtful 
cases we must regard as normal the one which moves more freely (to 
entrance of light, accommodation, and convergence), because spasm, 
as well as paralysis, diminishes the mobility. 

From the foregoing remarks it would follow that, in reflex rigid- 
ity of the pupils, the condition corresponds, so far as regards its dis- 
tribution, to homonymous hemianopsia, i.e., the nucleus of both 
sphincters is or is not innervated from each half of the field of vision. 
But cases of unilateral reflex rigidity of the pupil have also been de- 



DISEASES OF THE NERVOUS SYSTEM. 115 

scribed, for example, by Moebius {Centr. f. New., 1888, 23), and 
moreover the syraptom is often much more pronounced in one eye 
than in the other. This is probably owing to an affection in the 
immediate vicinity of one sphincter nucleus, which leaves the latter 
intact but interrupts all its optical connections. In this event the 
direct light reflex in the eye of the affected side would be wanting, 
but would be intact on the other side. The pupil on the healthy side 
would contract on the entrance of light into either eye. At the same 
time the reflex of accommodation and convergence might be present 
on both sides. This happened in Moebius' case. As a matter of 
course, however, such cases will occur rarely and the condition is 
probably only a temporary one. 

Some writers maintain that the nuclei of both pupillary sphincters 
are connected by fibres and thus explain the fact that both pupils are 
normally of equal size, even if light enters only one eye. The exist- 
ence of such fibres is denied by others. Anatomically a mutual con- 
nection by fibres between the two nuclei can hardly be denied. But 
inasmuch as fibres pass to both nuclei from each optic nerve, the ex- 
istence of connecting fibres is not absolutely necessary to explain the 
equal size of the pupils. 

In the clinical examination of diseases of the region of the nuclei 
of the ocular muscles greater attention should be paid than has 
hitherto been done, to the half-sided character of the symptoms (with 
regard to the field of vision). Motor disturbances (especially of the 
pupils) may also be homonymously half -sided in regard to the visual 
field, although no corresponding disturbance of vision is demonstrable. 
It is evident, therefore, that very accurate local diagnoses may be 
made in this way. 

Heddaeus and others apply the term reflex deafness to reflex in- 
sensibility of an eye in which, even when vision is intact, the en- 
trance of light does not produce direct or consensual stimulation of 
the pupil. I do not exactly understand why this term is taken from 
the organ of hearing. The more appropriate expression would be re- 
flex blindness (reflex amaurosis or amblyopia) or reflex half-blindness. 
Strictly speaking, the non-production of the light reflex of the pupil, 
despite its normal mobility, is not a disturbance of movement but 



116 THE EYE IN RELATION TO DISEASE. 

of vision, inasmuch as the cause is situated, not in the centrifugal 
motor paths, but in the centripetal (with regard to the nucleus) paths 
of optical conduction. 

As the pupillary movements are not influenced directly by the 
will (only indirectly through the impulse of accommodation and con- 
vergence), the reaction of the pupils to light takes place through the 
first reflex arc {vide page 87), within which involuntary move- 
ments are excited by unconscious sensory impressions. It is true 
that the impressions of light usually enter the field of consciousness 
after conduction in the primary optic ganglia, but this is not a neces- 
sary occurrence. As we have already seen (page 66), preserved re- 
action of the pupils to light despite the loss of vision is especially 
characteristic of cortical visual disorders. 

The pupillary movements are discussed in detail by Heddseus, 
Diss., Halle, 1880, and by Leeser, "Die Pupillarbewegungen," Prize 
Essay, Wiesbaden, 1881. 

A rare disorder of pupillary movement is the so-called hippus, 
^.e., rhythmical contraction and dilatation without change of illu- 
mination ; the number and extent of the oscillations may be very 
variable {vide Damsch, Neur. CentralbL, May 1st, 1890). It is 
observed in recovering paralyses of the motor oculi, and is then as- 
sociated with nystagmus. It is much rarer as an independent con- 
dition and is then found almost always in diseases such as tabes, 
multiple sclerosis, etc., in which there are frequent lesions in the 
region of the nuclei of the ocular muscles. In such cases it is the 
forerunner of reflex rigidity of the pupil. Nystagmus of the pupil 
is the most appropriate term for this condition. We must assume 
that, as a result of imperfect irritation or irritability of the muscle 
nucleus, the innervation takes place explosively, by fits and starts. 

Paradoxical reaction of the pupils — dilatation on the entrance of 
light, contraction on removal of light — is an extremely rare phenom- 
enon {vide Oestreicher, Berl kl, Woch., Feb. 10th, 1890). No suffi- 
cient explanation of this symptom can yet be given. Cases like that 
of Burchardt {Berl. kl. Woch., 1890, 2), in which the pupil was 
enlarged by contraction of the sphincter, in a case of coloboma of the 
iris and adhesion of one pillar, do not really belong in this category. 



DISEASES OF THE NERVOUS SYSTEM. 117 

The reaction of the pupil in convergence and accommodation is 
in part a purely mechanical process. During both acts a part of the 
blood contained in the ciliary body is pressed into the iris and the 
pupil is thus temporarily narrowed. In fact, this narrowing of the 
pupil must be regarded as an associated movement of vigorous in- 
nervation due to internuclear connections, in the same way that con- 
vergence to a certain distance is accompanied by a corresponding 
strain of accommodation. In peripheral paralysis or insufficiency of 
accommodation the increased impulse of accommodation will be 
manifested chiefly by such associated movements or will intensify 
them (internal squint in maximum innervation of accommodation) . 

The presence of the normal reaction of convergence and accom- 
modation with absence of the reaction to light shows that thenucleus 
of the sphincter pupillse and the nerve fibres originating from it are 
intact. On account of the close proximity of the individual groups 
of ganglion cells of the motor oculi nucleus, it is hardly possible that 
a lesion can affect only the connecting fibres between these groups. 

The dilatation of the pupil in deep inspiration and increased in- 
traocular pressure, and its contraction in expiration and diminished 
intraocular pressure, are purely mechanical processes. 

In spasm of the sphincter pupillse the pupil is more or less narrowed 
and reacts less freely to light, convergence and accommodation. The 
cause may be intraocular (inflammations, myotics) , or within the do- 
main of the motor oculi (meningitis) , or in the nucleus of the sphincter, 
although the real cause is situated more centrally. 

Dilatation of the pupil after cutaneous irritation is one of the 
sympathetic reflexes and hence is not lost in paralysis of the motor 
oculi. It is readily seen only after quite severe irritation in the 
neighborhood of the eye (head, face and neck) . As a rule it is uni- 
lateral, or at least much more marked on the side of the irritation 
than on the other. This reflex is absent in many peripheral anaes- 
thesias of the skin. It is retained in central anaesthesias (corona 
radiata, cortex, etc.) because the connection between the roots of the 
trigeminus and their sympathetic ganglia is not interrupted. 

We have already stated that the sympathetic supplies the dilatator 
pupillse, the fibres in the lids which moderately dilate the palpebral fis- 



118 THE EYE IN RELATION TO DISEASE. 

sure (dilatator palpebrarum), and Mueller's muscle, which closes the 
inferior orbital fissure and is able to push the globe slightly forward 
(protrusor bulbi). Hence, irritation of the sympathetic will cause 
moderate dilatation of the pupil with preserved although slightly 
diminished reaction to light; spastic dilatation of the palpebral 
fissure with perfect power of closure ; moderate protrusion of the eye, 
although its mobility is entirely free. At the same time the upper 
lid does not follow the eye in looking downward to the same extent 
as normally. Not infrequently the white sclera becomes visible above 
the cornea (v. Graefe's symptom in Basedow's disease). It is still 
doubtful whether the intraocular pressure is also increased ; dimin- 
ished power of accommodation is sometimes said to be present (Eulen- 
burg). As a rule this does not hold good. In pure affections of the 
sympathetic, accommodation, refraction and, usually, the intraocular 
pressure remain normal. 

In paralysis of the sympathetic narrowing of the pupil (myosis) 
is observed, together with normal reaction to light. The color of the 
iris often appears somewhat lighter because, on account of the con- 
traction, the coloring elements of the iris are distributed over a larger 
area. In addition there is slight drooping of the upper lid (ptosis) 
and slight retraction of the globe into the orbit (enophthalmus) . 
Diminution of intraocular pressure has often been mentioned, and to 
this is attributed the occasional increase in refraction. On the 
other hand, diminished accommodation has occasionally been seen 
on the side of the paralysis. If this is not accidental it is, at all 
events, very rare. Ocular pressure, refraction, and accommodation 
are usually unchanged. 

In 1869 Horner first gave a distinct clinical history of paralysis 
of the oculo-pupillary sympathetic fibres. Later his pupil, Nicati, 
furnished a somewhat schematic account of disease of the cervical 
sympathetic, beginning with irritative symptoms and passing into 
paralysis. Such cases are not very rare, and occasionally they may 
even lead to degenerative trophic changes in the face. Much more 
frequently there are pronounced paralytic phenomena from the start 
in some or all the branches. Irritative symptoms may last a long 
time without terminating in paralysis. The causes are injuries, 



DISEASES OF THE NERVOUS SYSTEM. 119 

tumors, inflammations, and suppurations which involve the cervical 
sympathetic. The cause is generally unknown or the patient at- 
tributes the condition to a cold. The affection of the sympathetic is 
found accidentally during examination for other diseases, as it pro- 
duces no annoying symptoms. 

Abnormalities in the size of the pupils of a central character may 
be divided accordingly into four classes : 

1. Paralytic cerebral mydriasis (paralysis of the sphincter). 

2. Spastic cerebral myosis (spasm of the sphincter). 

3. Paralytic spinal myosis (paralysis of the dilatator). 

4. Spastic spinal mydriasis (spasm of the dilatator) ; the latter form 
also includes dilatation of the pupil after cutaneous irritation. 

Those who deny the existence of a dilatator muscle of the pupil (a 
simple layer of smooth muscular fibres immediately in front of the 
posterior iris pigment) must explain the action of the sympathetic 
by an influence on the calibre of the vessels of the iris, narrowing in 
spasm and dilatation in paralysis. 

In addition to the oculo-pupillary symptoms, vasomotor disturb- 
ances in the corresponding half of the face and head are also observed 
in disease of the cervical sympathetic, viz., narrowing of the vessels 
in irritation, and dilatation in paralysis of the sympathetic. Kuss- 
maul distinctly saw blanching of the fundus oculi in irritation of the 
sympathetic. Corresponding changes are more readily seen in the 
integument of the face, such as unilateral sweating or absence of 
sweating, unilateral redness or pallor of the skin with several degrees 
difference in the temperature, and increase or diminution of the 
lachrymal secretion. 

As a rule, no influence is exerted upon the growth and nutrition 
of the parts, upon inflammatory processes, etc. At a later period, 
however, " trophic" disturbances are occasionally observed in disease 
of the sympathetic, but it is evident that another factor has then 
been superadded. In the same way peripheral anaesthesias usually 
exert no influence upon the tissue changes, while in other cases visi- 
ble " trophic" changes also develop. 

The so called " neuro-paralytic keratitis" is wrongly included 
among trophic disorders. It is not a disturbance of the growth 



120 THE EYE IN RELATION TO DISEASE. 

and nutrition of the cornea, but an entirely different process due to 
infection of a corneal ulcer. 

After injury or loss of substance of vascular tissues, with or with- 
out infection, when healing takes place the vessels play a prominent 
part, evidently as the result of the direct action of chemical or organ- 
ized irritants upon them. In non- vascular tissues this direct action 
upon the adjacent vessels is impossible or is only possible at a late 
period ; it takes place in a reflex manner, through the agency of the 
trigeminus and sympathetic, and is absent in anaesthesia of the 
former. Hence the course of recovery, especially of infected sur- 
faces, is modified and prolonged, but there is no real disturbance of 
nutrition or growth. 

If the peripheral sensory tracts are interrupted, the vascular re- 
flexes after sensory irritation, which are not absolutely local, are 
abolished, and this is particularly noticeable in non-vascular tissues. 
If the peripheral sympathetic tracts are abolished — and this, in view 
of their position, must always be associated with disease of the cor- 
responding vascular tract — a substitution may take place along col- 
lateral paths. But if the sympathetic ganglion cells are extensively 
diseased, genuine trophic disturbances make their appearance. 

In view of the connections of the sympathetic ganglia with the 
sensory nerves and the central nervous system, we can understand 
the fact that, from the start, the affection may assume the character 
of a sympathetic disorder or may develop from an anaesthesia or 
even start from the spinal cord (syringomyelia) . 

The peripheral sensori-sympathetic arc is situated outside of the 
skull and spinal cavity. 

But the sympathetic ganglia also receive centrifugal fibres from 
the central nervous system through the motor roots, and these exert 
a tonic or constricting influence on the muscular coats of the ves- 
sels. This is true with regard to the brain as well as the spinal 
cord. 

This explains the fact that in disease of an entire cerebral hemi- 
sphere unilateral symptoms of irritation or paralysis of the cervical 
sympathetic are found so frequently. But the local and sensori- 
sympathetic vascular reflexes are not abolished, indeed they are 



DISEASES OF THE NERVOUS SYSTEM. 121 

often exaggerated. This may be the most striking symptom of 
abolition of the influence of the central nervous system upon the 
sympathetic. 

The higher senses may also exert a tonic influence upon the ves- 
sels, especially upon those of the corresponding organ of special 
sense, and this is really done whenever the organ is engaged in a 
function which excites the ^faculty of attention. If, for example, the 
activity is confined to a single special sense, the central tonic 
action upon the other senses is abolished. In this way purely func- 
tional disorders of the latter may be produced, in the sense of "not 
seeing and hearing what is going on." If this affects all the senses 
sleep will result. This condition will again be referred to repeatedly 
in discussing hysteria, hypnosis, sleep, trophoneuroses, traumatic 
neuroses, etc. 

The sympathetic fibres for the eye probably run along with the 
motor fibres in the corona radiata and internal capsule, and also along 
the locality from which Lannegrace has produced unilateral visual 
disturbances of the opposite eye. 

In such visual disorders no abnormal fulness of the vessels can 
be seen either without or within. For certain reasons it seems prob- 
able to me that the effect is produced in the nerves which emerge 
from the cranial cavity. Interference or facilitation of conduction 
at the places where the nerves pass through bony foramina would 
best explain the symptoms in question. 

Hence there are three kinds of sympathetic reflexes: 1, the local 
reflex at the site of irritation ; 2, the peripheral sensori -sympathetic 
reflex arc ; and 3, the central reflex arc, which passes through the 
brain or spinal cord. The reflexes are unconscious in all three kinds, 
but in the third reflex arc they are voluntary in so far as they consist 
of associated innervation in motor impulses or in inhibition of such 
impulses. Under certain circumstances these may be employed for 
definite purposes, for example, when the whole attention is devoted to 
visual or auditory impressions. 

The very intense innervation of the vessels in violent emotions, 
such as fright, fear, shame, and anger, are effected through the 
third sympathetic reflex arc. Such temporary violent innervation 



122 THE EYE IN RELATION TO DISEASE. 

after severe fright may pass directly into permanent paralytic symp- 
toms (so-called traumatic neuroses) . 

In ordinary paralysis of the sympathetic we have to deal essen- 
tially with the loss of the central tonic influence of the brain or spinal 
cord. The ganglion cells of the sympathetic and the centrifugal 
fibres emerging from them are intact, together with the reflexes in 
the local and middle sensori-sympathetic arcs. The latter may even 
be considerably exaggerated. 

A very material characteristic of all these symptoms is their 
unilateral character, but, as a matter of course, they may also occur 
on both sides. 

We have already seen that the oculo-pupillary centre in the spinal 
cord is situated below the vasomotor centre for the vessels of the 
head, and that the fibres consequently pass through the nerve roots 
to the sympathetic ganglia at different levels. If the trunk of the 
sympathetic is affected the oculo-pupillary and vasomotor symptoms 
will appear, as a rule, at the same time or in brief succession. 

If the lesion is localized in the cord or at the nerve roots, the 
oculo-pupillary or vasomotor symptoms often appear singly, or only 
single symptoms make their appearance, such as myosis, or ptosis 
and myosis. Oculo-pupillary irritative and vasomotor paralytic 
symptoms may also be combined, or vice versa. In diseases of the 
spinal cord the presence or absence of these symptoms is of great 
diagnostic importance, and this is also true concerning lesions of the 
roots of the brachial plexus. In the latter the oculo-pupillary symp- 
toms are a characteristic feature of the "inferior type." In lesions 
of the brachial plexus proper, however, sympathetic symptoms are 
no longer observed because the fibres to the sympathetic ganglia are 
given off before the plexus is formed. 

Disturbances in the lachrymal secretion are, in the main, vaso- 
motor sympathetic symptoms, located chiefly in the middle and 
partly in the central reflex arc (weeping without physical pain, aboli- 
tion of the secretion of tears in the weeping of many insane, etc.). 
We are not justified, however in applying the term "tear centre" 
to parts of the brain from which disorders of the lachrymal secretion 
may be produced. It is evident that there is merely interruption or 



DISEASES OF THE NERVOUS SYSTEM. 



123 




disturbance of conducting paths. Nervous epiphora may precede and 
accompan}^ diseases of the brain and spinal cord. 

C. Relations between the Blood-Vessels and tlie Eye. 

1. Arteries. — With the exception of a part of the lids the eye is 
supplied by the cerebral ^ arteries, a fact which accords with the 
development of the organ from the mid-brain. 

Fig. 16 shows the distribution of the large vessels at the base of 
the brain, according to Mer- 
kel ("Handb. d. topogr. 
Anat.," Bd. 1). 

The internal carotid 
passes through the caver- 
nous sinus in a double arch 
and then gives off the oph- 
thalmic artery, which passes 
through the optic foramen 
below and to the outside of 
the optic nerve into the or- 
bit. The central artery of 
the retina, derived from the 
ophthalmic, enters the trunk 
of the nerve with the corre- 
sponding vein from below and the outside, about 1-1^ cm. behind the 
eye. A few little" twigs pass to the optic tract, chiasm and first 
part of the optic nerve, from the trunk of the carotid which lies in 
the outer angle of the chiasm. 

The carotid then divides into its two terminal branches. The 
anterior cerebral artery passes forward at a right angle and com- 
municates at once with the corresponding artery of the opposite side 
(anterior communicating branch) . It passes to the first and second 
frontal convolutions, to the medial surface of the cerebrum as far as 
the cuneus (including the praecuneus and excluding the occipital and 
parietal lobes) and to the inner half of the inferior surface of the frontal 
lobe. The second branch of the carotid, the middle cerebral artery, 
passes into the Sylvian fissure and is distributed to the first frontal 



Fig. 16.— Arteries at the Base of the Brain, after 
Merkel. R, Olfactory nerve ; CK chiasm ; nlll, nIV, 
?iFI, third, fourth, and sixth cranial nerves; B, pons; 
Ci, internal carotid; ay, vertebral artery; ab, basilar 
artery; aca, anterior cerebral artery and anterior 
communicating; acm, median cerebral artery; acop, 
posterior communicating artery : acj), posterior cere- 
bral artery; acls, superior cerebellar artery. 



124 THE EYE IN RELATION TO DISEASE. 

convolution, insula, convexity of the parietal lobe, first temporal 
convolution and a part of the second, and the outer half of the lower 
surface of the frontal lobe. 

Posteriorly the carotid sends beneath the optic tract the posterior 
communicating branch to the posterior cerebral artery. The latter 
is the terminal branch of the basilar artery which is formed by the 
union of the two vertebral arteries. The posterior communicating 
branch runs along the motor oculi nerve and sends branches to the 
chiasm, infundibulum, hypophysis, and anterior part of the optic 
thalamus. From it is usually derived the anterior choroideal artery 
which supplies the choroid plexus. 

The posterior cerebral artery supplies the rest of the cerebral hemi- 
sphere, viz., the occipital lobe, the inner and lower surface of the 
temporal, lobe, and the largest part of the second temporal con- 
volution. 

The areas of supply of the middle and posterior cerebral arteries 
meet at the parieto-occipital fissure, the cuneus, also known as Noth- 

nagel's perceptive centre, or as 
the macular locality of other 
writers (vide Fig. 17) . It fol- 
lows that this locality is espe- 
cially favored as regards its sup- 
ply of blood. For example, in 
occlusion of the posterior cere- 
bral artery, this part may still 

Fig. 17.-DistributH3n of the Three Large Cere- receive nourishment while the 
bral Arteries over the Convexity, after Merkel. 

Distribution of the anterior cerebral artery remainder of the OCCipital COrtCX 
shaded horizontally; that of the median, ob- 
liquely ; that of the posterior, vertically, fpa, is destroyed. This explains very 

Parieto-occipital fissure. • i j.i • j. £ n 

Simply the persistence oi a small 
central remnant of the field of vision in bilateral homonymous 
hemianopsia due to embolism in the occipital lobes (vide the cases of 
Foerster, Schweigger, and others on page 61) . I may also remark 
that the same relation holds good concerning the auditory centre in 
the second temporal convolution. 

According to Heubner all these arteries terminate in the same 
way. They give off at right angles numerous small branches to the 




DISEASES OF THE NERVOUS SYSTEM. 125 

basal ganglia. The anterior cerebral artery supplies the head of the 
caudate nucleus, the most anterior part of the base, the infundibulum, 
chiasm, optic nerve and corpus callosum. The middle cerebral artery 
passes through the lateral perforated space, and in the first centimetre 
of its course supplies the anterior limb of the internal capsule, the 
inner part of the lenticular nucleus, etc. ; in its second centimetre it 
supplies the lateral and upper part of the lenticular nucleus, caudate 
nucleus and external capsule. The posterior cerebral artery passes 
through the middle perforated space to the cerebral peduncles, cor- 
pora quadrigemina, lateral part of the optic thalamus, choroid plexus 
of the third ventricle, etc. 

All arteries of the basal region are end-arteries, i.e., they only 
anastomose with one another by means of the capillaries. It is not 
until the arteries have run a course of 2 to 3 cm. that they divide 
dichotomously in the pia mater, and these branches exhibit numer- 
ous anastomoses. They give off numerous lateral branches, short 
and fine ones to the cortex, longer and larger ones to the medullary 
substance ; these vessels constitute end-arteries. The arteries of the 
cortex are especially liable to embolism ; the small vertical branches 
of the basal region show a predisposition to diseases of their walls, 
and to the formation of aneurism and thrombosis. 

All other parts of the cerebrum and cerebellum and the nerves from 
the third to the twelth are supplied by the basilar and vertebral ar- 
teries. Each nerve receives small branches which run in part cen- 
trifu gaily, in part centripetally as far as the nuclei. The ninth, 
tenth, eleventh and twelfth nerves are supplied by the vertebral 
arteries, the seventh and eighth nerves by their point of union, and 
the seventh and third nerves by the basilar arter3\ From all three 
a series of vessels passes in the median line as far as the floor of 
the fourth ventricle; from the vertebral artery they go as far as 
the lower border of the pons ; from the basilar they pass to the pons, 
the floor of the fourth ventricle, and the beginning of the aque- 
duct of Sylvius. 

Each nerve nucleus thus receives arterial blood from two sides, 
from the branches just mentioned, and from the centripetal branches 
in the nerves. The anterior part of the motor oculi nucleus also re- 



126 THE EYE IN RELATION TO DISEASE. 

ceives blood from the posterior cerebral artery, the posterior part 
from the basilar artery. This furnishes the possibility of an inde- 
pendent affection of each division. 

The lateral parts of the floor of the fourth ventricle also receive 
blood from the choroid plexus. 

The cerebellar arteries are derived from the basilar and vertebrals, 
and include the posterior inferior and anterior inferior cerebellar 
arteries and the superior cerebellar artery. The latter emerges from 
the basilar at the anterior border of the pons, passes between the 
motor oculi and trochlearis nerves to the pons, then to the middle 
cerebellar peduncle, superior vermis, valve of Vieussens, corpora 
quadrigemina, choroid plexus of the third ventricle, etc. 

To give a brief resume of the vascular supply of some important 
parts of the brain : 

The internal capsule receives its supply anteriorly from the middle 
cerebral artery, posteriorly from the anterior choroideal artery or 
the posterior communicating artery. 

The optic thalamus is supplied anteriorly by the posterior commu- 
nicating branch, posteriorly by the posterior cerebral artery. 

The posterior cerebral commissure and the pineal gland are sup- 
plied by the anterior cerebral artery, the latter also by the posterior 
cerebral and the superior cerebellar artery. 

The optic tract is supplied by the trunk of the carotid, the 
posterior communicating and posterior choroideal arteries; the 
chiasm and optic nerve are supplied by the carotid, anterior cerebral, 
communicating and posterior arteries. 

The corpora quadrigemina are supplied by the posterior cerebral 
and superior cerebellar arteries. 

The pons, by the basilar and superior cerebellar arteries ; the 
choroid plexus of the fourth ventricle is supplied by the posterior 
inferior cerebellar artery. 

The occipital lobe is supplied by the posterior cerebral artery, its 
macular portion by the middle cerebral ; the region of the anterior 
cerebral artery also passes, on the inner surface of the hemisphere, 
to the border of the visual sphere. 

2. Veins. — The veins in the skull and orbit are destitute of 



DISEASES OF THE NERVOUS SYSTEM. 127 

valves. The larger trunks are very variable and anastomose freely 
with one another; the small ones accompany the arteries, the large 
ones do not. According to Merkel the small veins within the brain 
substance no longer anastomose with one another. 

The superior cerebral veins from the anterior and upper part of 
the hemispheres and a part of the median surface empty into the 
superior longitudinal sinus ; the middle veins from the anterior horn, 
corpus striatum, inferior horn, optic thalamus, peduncles, internal 
capsule, base of the brain, inferior surface of the occipital lobe, upper 
and lower part of the cerebellum, pass in the vena magna Galeni to 
the sinus of the tentorium; the inferior cerebral veins from the 
temporal and occipital lobes, cerebellum 
and parts of the base pass to the petrosal, ^ ' ' 

transverse and cavernous sinuses. 

The orbit contains two principal veins, 
the superior and inferior ophthalmic veins, 
which freely anastomose with one another, 
particularly in the vicinity of the optic fora- 
men and immediately behind the globe. f^«- is- -frontal section of 

the Cavernous Sinus, after Mer- 

The superior ophthalmic vein passes through kei. sc, cavernous sinus; i?, 

hypophysis; Ci, internal caro- 

the superior orbital fissure to the cavernous tid; iii, iv, fz, oculomotor, 

J 1 • r ' Till* j_' • 1 trochlearis and abducens 

smus; the inferior ophthalmic empties into ^^^^^^. y ^^ ^^ 3^ ^^^^ 3,^^^^^ 
the deep facial vein. Both have numerous ^"^ ^^'""^ branches of the tn- 

geminus. 

connections with the veins of the cheeks, 

lids, nose, and temporal region. None of them possesses valves. 

The central vein of the retina usually empties into the superior 
ophthalmic, but often passes through the superior orbital fissure 
directly into the cavernous sinus. 

D. Relations between the Eye and the Lymphatics. 

The membranes covering the optic nerve pass directly into the 
cerebral meninges at the optic foramen, to whose upper wall the 
nerve is quite firmly adherent. Hence the subdural and subarach- 
noid spaces of the optic nerve communicate with the corresponding 
ones within the skull. 

The lymphatics in the brain are mainly perivascular and ac- 





128 THE EYE IN RELATION TO DISEASE. 

company the veins. They leave the skull through the carotid canal, 

the jugular foramen, and with the vertebral artery to the upper deep 

cervical glands. The outflow of lymph in the subarachnoid and 

subdural spaces of the optic nerve and the current 

\ ^ //// ^^ lymph in the nerve itself appear to be directed 

Ik /#/ toward the cranial cavity. 

If an injection is made, under moderate press- 
ure, into the tissue of the nerve in a direction to- 
FiG. 19.— Plastic In- Ward the cranial cavity, the fluid does not pass 
Optic NeTv^ i^in^the beyond the chiasm into the tractus, but transversely 
direction toward the across the anterior half of the chiasm to the other 

chiasm, Ch ; E, right 

optic nerve; T, optic optic nervc, along which it runs in the same way 
as if it were directly injected in a centrifugal direc- 
tion. The injected fluid extends farthest forward in the axial bun- 
dles of the second optic nerve. (This experiment is not easy and 
may at first trial fail; with practice it can be done with certainty.) 

This explains the fact that inflammatory processes — whether 
infectious or non-infectious — may spread from one eye to the other 
without giving rise to notable cerebral symptoms. This is true not 
alone of so-called sj'mpathetic ophthalmia but also of an entire series 
of inflammatory affections, especially of the choroid. 

The lymphatics of the orbit which are connected with Tenon's 
capsule empty mainly into the deep glands of the face ; the lymphat- 
ics of the lids and conjunctiva pass into the glands in front of the 
ear and below the inferior maxilla. 

The facts and hypotheses hitherto presented furnish the material 
from which we may make a local diagnosis of affections of the organ 
of sight (in the broadest sense of the term) . The subject becomes 
more complicated from the fact that diseases within the skull, espe- 
cially when they develop suddenly, may give rise to remote symp- 
toms which are due to an implication of parts of the brain that are 
not directly affected by the disease. The remote symptoms usually 
disappear gradually, and it is only those which persist after the lapse 
of weeks or months that may be utilized for accurate local diagnosis. 
The greatest part of what is known as " the vicarious action of 



DISEASES OF THE NERVOUS SYSTEM. 129 

other parts of the brain" must be attributed to the gradual disappear- 
ance of the remote symptoms. For example, the phenomena ob- 
served in small circumscribed destructions of the cortex at the 
periphery of the visual sphere are almost exclusively remote symp- 
toms. 

The remote symptoms also include those instances in which, for 
example, an adjacent or even a distant nerve is pressed against a bony 
process or a tense artery and is made incapable of conduction. For 
example, isolated paralysis of the abducens sometimes results from 
a growth in the opposite hemisphere. 

Apart from the focal symptoms, a comparatively small lesion may 
give rise to irritative or paralytic symptoms of an entire hemisphere 
or even the entire brain, at another time it may produce only remote 
symptoms in a certain direction, and in a third case it may produce 
none at all. Many progressive lesions are surrounded by a zone of 
irritation which finally gives rise to paralysis. This is observed 
not infrequently at the base of the brain where the nerves are at- 
tacked in succession. 

The irritative zone of remote symptoms is usually situated farther 
away from the original lesion than the paralytic manifestations. 

Diseases of the cerebellum, pons, pineal gland, optic thalamus, and 
other parts near the region of muscle nuclei may or may not be at- 
tended with spasms and paralyses of the ocular muscles. In like 
manner, lesions near the optic tract and chiasm may or may not be 
associated with disorders of vision. In unilateral lesions of the pons 
paralysis of the ocular muscles is on the side opposite to the hemi- 
plegia, because the motor parts decussate in the medulla. In diseases 
of the posterior limb of the internal capsule central disturbances of 
vision and disturbances of sensation are usually combined. 

In addition to the visual symptoms which may be utilized for 
local diagnosis there are other symptoms of which we maj^ avail our- 
selves — such as exophthalmus, oedema of the lids, chemosis, choked 
disc, neuritis, atrophy of the optic nerve, diseases of the choroid and 
retina, etc. These permit an inference with regard to the character 
of the disease, rather than its location. 



130 THE EYE IN RELATION TO DISEASE. 

E. Individual Diseases of the Brain, Cord, and Nerves. 

After this detailed introduction we may be comparatively brief 
in our remarks on the implication of the organ of vision in the indi- 
vidual diseases of the nervous system. In many of them the eye 
symptoms are extremely important and characteristic, and determine 
the diagnosis and treatment. As we shall see, they often throw 
light on the interpretation of the whole disease. 

1. Diseases of the Brain. 
Ancemia and Hypercernia of the Brain and its Membranes. 

In these two conditions it is to be supposed that the status of the 
vessels of the retina and the entrance of the optic nerve (which derive 
their blood supply from the same source as a large part of the brain) 
would furnish a picture of the vascular condition of the brain, espe- 
cially of the cortex and the pia mater. This expectation, however, is 
far from being realized. In the first place, the amount of blood in 
the brain does not depend solely on the internal carotid (from which 
the ophthalmic artery takes its origin) but from the entire supply to 
the circle of Willis. For example, changes in the amount of blood 
in the carotid may appear only in the retina, where the}' give rise to 
hypersemia or anaemia, while the amount of blood in the brain re- 
mains unchanged. 

In many cases, however, the amount of blood in the pia mater and 
in the retina is similar. The slight degrees of change are demon- 
strable with difficult}^ or not at all, because the calibre of the vessels 
varies normally within very wide limits. Hence it is difficult to 
recognize slight hypersemia or anaemia of the retina or papilla unless 
by comparison with the healthy eye. As a rule this is impossible in 
diffuse affections of the brain. 

It may even happen that the retina exhibits the opposite condition 
to what must be assumed to exist in the brain. The retinal findings, 
especially when hypersemic in character, must therefore be relied 
upon with caution in assuming an analogous condition within the 
cranium, and with a due regard for all other circumstances. 



DISEASES OF THE NERVOUS SYSTEM. 131 

This is particularly true of acute conditions. In more or less 
chronic diseases the vascular conditions in the brain and retina 
gradually appear to become alike, as is seen, for example, in the 
constant venous hypersemja of the retina in epilepsy of long standing. 

Hypersemia of the retina is often found, is often absent, in brain 
diseases of all kinds, but it is constant in none. The apparent 
hypersemia of a very hypermetropic eye, especially in young people, 
or the hyperaemia of the papilla and retina, even amounting to true 
neuritis, which is a constant symptom at the beginning of myopia, 
cannot be utilized for diagnostic purposes as regards brain disease. 
Particularly in threatening myopia is the diagnosis not easy. 

Apart from the ophthalmoscopic findings, the symptoms of 
cerebral congestion are usually said to be restlessness, irritability, 
diffuse headache and narrow pupils ; those of cerebral ansemia are 
drowsiness by day, sleeplessness at night, circumscribed headache 
and dilated, sluggish pupils. On the other hand Corning {N. Y. 
Med. Rec, 13, XI, 87) states that a dilated pupil is found in con- 
gestion, a contracted pupil in ansemia, but this is probably not true 
of the majority of cases. 

Cerebral Hemorrhages. 

As a rule cerebral hemorrhages develop suddenly, so that, at 
the start, the remote symptoms predominate. The function of both 
hemispheres may be abolished quite suddenly. In a little while 
the symptoms are confined to one hemisphere — hemiplegia or 
hemiansesthesia with or without disturbance of speech. Very often 
there is also homonymous hemianopsia in the visual field of the 
side opposite to the hemorrhage, but this usually disappears in a short 
time unless the visual zone or the optic radiations in the corona 
radiata are the site of hemorrhage. Gowers {Brit. lied. Journ., 
Isov., 1877) first called attention to the frequent occurrence of 
temporary hemianopsia in apoplectic hemiplegia; this is espe- 
cially true of the period during which conjugate deviation of the 
head and eyes is present. The latter symptom is very frequent in 
cerebral hemorrhage, and takes place toward the side of the lesion. 
We have already stated that this symptom, in our opinion, is due 



132 THE EYE IN RELATION TO DISEASE. 

to irritation of the opposite hemisphere. Hence, in the exceptional 
cases in which the deviation takes place toward the side opposite 
to the lesion, the hemorrhage has either been situated far forward in 
the frontal brain (remote from the visual sphere, which is the most 
important part of the cortex so far as concerns the motor oculi nerve), 
or it has been very small (Lepine, Rec. d^Ophth., 1876, p. 280). In 
these cases the occipital cortex is not included in the paralytic zone, 
but in the zone of peripheral irritation. In paralysis of one hemi- 
sphere without irritation of the other, voluntary associated movements 
toward the opposite side are abolished to a greater or less extent. 
This is also a frequent temporary symptom in cerebral hemorrhage. 

Sudden homonymous hemianopsia may be the sole symptom, 
apart from temporary dizziness, of a hemorrhage into the brain. If 
there is hemiopic reaction of the pupils, the lesion is situated in 
the optic tract or primary optic ganglia. If the pupils react normal- 
ly, it is usually situated in Gratiolet's fibres, because such sudden 
hemianopsias are generally permanent. As a matter of course, a 
hemorrhage which produces only homonymous hemianopsia must be 
a small one, and a small hemorrhage into the visual cortex can only 
give rise to permanent hemianopsia when it destroys the entire 
perceptive centre. A hemorrhage of such dimensions, however, 
always causes initial remote symptoms. 

The term " signe de I'orbiculaire" is applied by French writers to 
the inability of hemiplegics to close only the eye of the paralyzed 
side. This would be a sign of cortical weakness of the orbicularis 
palpebrarum, i.e., of voluntary closure of the eye. The symptom 
loses much of its importance, however, from the fact that many 
healthy individuals are unable to close each eye separately. 

Every cerebral hemorrhage forms a focus of destruction, sur- 
rounded by a zone of paralyses and, at a greater distance, by a zone 
of irritation. If the hemorrhage is not followed by inflammation, by 
which the condition becomes a progressive one, the remote irrita- 
tive symptoms, which usually include conjugate deviation, first 
disappear, and then disappear the symptoms of the paralytic zone ; 
under these are included hemianopsia and the inability to perform 
associated movements of the eyes toward the side opposite to the 



DISEASES OF THE NERVOUS SYSTEM. 133 

lesion, unless these are due to direct destruction. It is not rare that 
paralytic symptoms disappear with the onset of irritative phenomena 
in the previously paralyzed part, such as visual hallucinations, 
spasms and twitchings ; for example, associated twitchings toward 
the side opposite the lesion, when conjugate movements in that 
direction had been previously paralyzed. 

Finally, the symptoms become restricted to those due to the loss 
of the directly destroyed region, and apparent complete recovery may 
ensue. On careful examination, however, we are usually able to de- 
monstrate slight defects in the province of some of the organs of 
special sense, or of motor activity, or in the general mental con- 
dition (memory, change of character, etc.). 

From these statements it is evident that an accurately local 
diagnosis can hardly ever be made except at the very beginning of 
the attack or after all the remote symptoms have run their course. 

If a hemorrhage ruptures outward into the subarachnoid and 
subdural space, basal symptoms are produced, such as spasms and par- 
alyses, anaesthesias and parsesthesias of the nerves at the base, the 
chiasm, etc. The blood may enter the sheath of the optic nerve and 
produce changes which are visible with the ophthalmoscope (choked 
disc). This is often attended with dilatation of the pupils, probably 
from pressure on the motor oculi nerve. In one-half of his cases of 
cerebral hemorrrhage Hutchinson observed rigid mydriasis on the 
side of the lesion, and believes that this is a very important sign. It 
is probably due in most cases to paralysis of the motor oculi from 
pressure on the nerve, occasionally to irritation of the sympathetic, 
or to both. Mydriasis is also observed in meningeal hemorrhages, 
usually on the same side ; more rarely it is bilateral on account of 
the extension of the hemorrhage; myosis is very rare. White 
{Brain, 1886, p. 532) and Seeligmueller {Arch. /. hi. Med., XX, 
p. 101) have called attention to permanent paralysis of the oculo- 
pupillary sympathetic fibres on the same side as the hemorrhage, i.e., 
crossed with regard to the general paralytic symptoms. 

If the extravasation perforates into the ventricles decided nar- 
rowing of the pupils is a striking symptom. As this is also observed 
in hemorrhages near the nuclei of the ocular muscles, for example, 



134 THE EYE IN RELATION TO DISEASE. 

into the pons, it is probably due to direct irritation of the sphincter 
nucleus. 

Symmetrical hemorrhages may also occur on both sides. Chauf- 
fard {Rev. de Med., 1888, No. 2) reports a case of blindness from 
bilateral destruction of the optic radiations. 

Ophthalmoscopic findings which may be attributed directly to 
cerebral hemorrhage are very rare. Neuritis or choked disc, with 
or without retinal hemorrhage, is occasionally observed : it terminates 
in recovery or in partial or complete atrophy of the optic nerve. 
Bristowe (Ophth. Rev., March 20th, 1886, p. 88) describes bilateral 
optic neuritis (probably choked disc) with hemorrhages in a case of 
sudden hemiplegia with unconsciousness. The diagnosis of cerebral 
tumor was made, but a hemorrhage, as large as a pigeon's Q^^, was 
found in the left optic thalamus. It extended to the posterior border 
of the internal capsule, to the white substance of the temporal lobe, 
and to the posterior part of the lenticular nucleus. A few similar 
cases have been reported. In all such cases the hemorrhage must be 
large, and the extravasation into the optic sheath, and eventually the 
choked disc, if unilateral, will be found upon the same side as the 
hemorrhage. 

Choked disc is found somewhat more frequently in pachymenin- 
gitis hsemorrhagica, the symptoms of which resemble those of tumor 
with intercurrent hemorrhages {vide Tuczek, Wien. 7ned. Blaetter, 
1883, 12, and Zacher, Neur. Centralbl, 1885, p. 125). 

Complete or partial atrophy of the optic nerve also takes place 
when the hemorrhage has destroyed the primary optic ganglia, 
tractus, chiasm or optic nerves, or has exercised upon them a pres- 
sure which terminates in degeneration. 

On the other hand the eye often exhibits signs which have noth- 
ing to do with the existing cerebral hemorrhage but are attributable 
to the same causes as the latter. For example retinitis, neuritis 
and albuminuric neuro-reti"nitis are signs of similar changes in the 
brain : simple retinal, vitreous, and other hemorrhages are evidences 
of a wide-spread atheromatous process. Atheroma of the vessels 
is often seen with the ophthalmoscope (thickening of the walls, 
narrow column of blood in places, etc.). In rare cases the walls are 



DISEASES OF THE NERVOUS SYSTEM. 135 

found to be of a yellowish color in patches, particularly upon the 
papilla, or miliary aneurisms are found to correspond with similar 
changes in the brain. 

The spontaneous, rapidly disappearing, but easily relapsing 
hemorrhages of the conjunctiva and retina in old people are of seri- 
ous significance and betoken possible hemorrhage into the brain. 

Embolism and Thrombosis. 

An embolus produces the same symptoms, in general, as a hemor- 
rhage and in many cases can hardly be distinguished from the latter. 
If it is infectious it gives rise to an abscess of the brain, and the 
symptoms are those of the latter affection. If it is not infectious, a 
spot of softening will develop. The latter will also develop, although 
not so suddenly and with fewer remote symptoms, in thrombotic 
processes which may occur as the result of various diseases of the 
cerebral vessels. 

Spots of softening are by far the most important brain diseases, 
as regards local diagnoses, because they furnish the purest focal 
symptoms after the termination of the brief period of reaction. Most 
of our knowledge of more accurate local diagnosis in man is based 
upon the clinical symptoms in such cases. 

Complications are very rare. In only one case of softening of the 
occipital lobe is mention made of double choked disc, which disap- 
peared later (Wilbrand, Arch. /. Ophth., XXXI, 3, 319). This is 
probably not more frequent in softening of other parts of the brain. 

A number of cases of bilateral symmetrical softening of the optical 
centres have been observed (Oulmont, Gaz. Hebd., 1889, No. 38; 
Bouveret, Eev. gen. d' Ophth., 1887, p. 481; Berger, Ref. Jahr. f. 
Aug., 1885, p. 289). 

Thromboses of the cavernous sinus act differently, according as 
they are infectious (following caries of the petrous portion of the 
temporal bone) or non-infectious (marantic thrombosis). In the 
former event they usually furnish the symptoms of a cerebral abscess 
together with those of suppuration of the orbital cavity (swelling 
of the lids, protrusion and irnmobility of the eye, dilated and rigid 
pupil, blindness, insensibility of the conjunctiva and cornea, ulcera- 



136 THE EYE IN RELATION TO DISEASE. 

tion of the cornea, suppuration of the eye, etc.). So long as the 
thrombus has not extended to the ophthalmic vein, the ophthal- 
moscopic appearances may be tolerably normal. But after this has 
taken place, we find pronounced venous stasis of the retinal veins 
and more or less abundant retinal hemorrhages, while the entrance 
of the optic nerve is very red but usually not much swollen. 

These ophthalmoscopic appearances are found more frequently in 
the more slowly progressing marantic thromboses, but only when 
the thrombus has extended to the ophthalmic vein. Otherwise the 
current of blood may pass through the posterior facial vein. After 
injections of wax into the cavernous sinus Ferrari found no stasis of 
the retinal veins; this took place only when the wax entered the 
ophthalmic vein itself. 

In non-infectious thrombosis of the sinus, we find, apart from 
general cerebral symptoms, mainly basal symptoms, viz., paralyses 
of the motor oculi nerves which pass near the sinus (vide Fig. 18), 
rigid and dilated pupil, insensibility of the trigeminus, especially of 
the cornea and conjunctiva, impairment of sight or even blindness 
due to interruption of conduction in the optic nerve, etc. 

CEdema of the lids and protrusion of the eye then indicate that 
the process is located in the vicinity of the orbital cavity. All these 
symptoms may likewise occur in meningitis, and hence the ophthal- 
moscopic appearances may decide the diagnosis. In meningitis 
venous congestion and even pronounced neuritis may occur, but the 
marked stasis of the retinal veins, which is found in thrombosis of 
the sinus with thrombosis of the ophthalmic vein, is never observed. 

Abscess of the Brain. 

The symptoms of abscess of the brain consist of those of a tumor 
combined with those of a purulent infectious inflammation. The 
destroyed parts of the brain do or do not give rise to symptoms, ac- 
cording to their location, so that a stationary abscess may long re- 
main latent. 

In progressive suppurations the destroyed part is surrounded by a 
zone which gives rise to irritative symptoms, passing later into 
paralysis. In rapidly advancing suppuration the remote symptoms 



DISEASES OF THE NERVOUS SYSTEM. 137 

may even extend to the opposite hemisphere, so that great caution 
is necessary in utilizing cerebral abscesses for local diagnosis. 

Choked disc is found frequently, though not so often as in tu- 
mors ; neuritis is also frequent, but the most frequent is " obstructive 
neuritis," t.e., there is slighter swelling but more pronounced inflam- 
matory phenomena than in typical choked disc. This " obstructive 
neuritis" is the most characteristic ophthalmoscopic finding in abscess 
of the brain. As a rule the lesion is bilateral though more marked 
on one side. But if the neuritis is unilateral or much more marked 
on one side it is generally found on the same side as the abscess. 
The latter is then located commonly in the anterior parts of the 
brain, the frontal or temporal lobes. For example, Greenfield {Brit. 
Med. Journ.^ 12, II, 1887) reports a case of abscess of the left tem- 
poral lobe after otitis, with left optic neuritis and paralysis of the 
left motor oculi nerve, which recovered after trephining. 

The impairment of sight is often very considerable, varying from 
losses in the field of vision and color disturbances to complete blind- 
ness. Vision is rarely normal or nearly so. In one case of cerebral 
abscess, Nauwerck (Deiitsch. Arch. f. hi. Med., XXIX, p. 1) found 
that the optic nerve was elevated and very much reddened, but there 
was no disturbance of sight. 

In abscesses near the base of the brain, oedema of the lids, pro- 
trusion of the globe, pain and photophobia may appear even prior to 
perforation, as in purulent meningitis. 

Conjugate deviation of the eyes and head usually takes place to- 
ward the side of the abscess, but there are also exceptions to this 
rule, particularly when the abscess is remote from the occipital lobe 
(Roussel, Prog. Med., 1886, No. 29). 

Apart from infectious emboli, suppurations in the ear are the 
most frequent cause of abscesses of the brain : and about 60 per cent 
are situated in the temporal or lower part of the parietal lobes, while 
about one-third are found in the cerebellum. See Hessler in 
Schwarze's " Handbuch der Ohrenheilkunde," Bd. II, p. 634 (Ed.) 

In a number of such cases ptosis has been mentioned as a symp- 
tom, and must then be regarded as cortical in character. In one 
case Heinecke [Muench. med. Woch., 1889, p. 571) observed bilateral 



13^ THE EYE IN RELATION TO DISEASE. 

ptosis and retinal hemorrhages, the latter probably of a septic char- 
acter. 

The rupture of an abscess into the cranial cavity gives rise to the 
symptoms of a purulent meningitis, viz., basal spasms, paralyses, and 
sensory disturbances, neuro-paralytic keratitis, etc. Perforation into 
the ventricles is usually rapidly fatal; this is atlencled by extreme 
myosis, probably from direct irritation of the sphincter nuclei. 

All remote symptoms, especially the irritative ones (blindness, 
paralyses, optic neuritis, etc.), may subside after evacuation of the 
pus, but losses of the field of vision, color disturbances, and more 
or less pronounced visual disorders may be left. Symptoms which 
are due to suppuration and destruction of tissues persist after the 
evacuation of the pus. Irritative symptoms (spasms) prove that the 
corresponding part of the brain is not destroyed. Hence, restoration 
of function of the groups of muscles in question may be expected 
after a successful operation. 

In abscesses of the brain, accordingly, the organ of sight may not 
alone exhibit important local symptoms (hemianopsia, conjugate 
deviation, paralyses, etc.), but the demonstration of "obstructive 
neuritis" at the entrance of the optic nerve warrants a very probable 
diagnosis of the character of the disease. 

Tumors of the Brain. 

Tumors of the brain may long run a latent course if they develop 
in a part whose destruction causes no noticeable local symptoms, and 
if their growth is slow so that the adjacent parts may yield. This 
may even happen in the immediate vicinity of those parts whose 
irritation or destruction causes the most striking local symptoms, 
for example, in the region of the muscle nuclei. In such cases we 
must assume that the tumor simply displaces the adjacent tissues 
but does not destroy them or even interfere materially with their 
functions. It is evident that pressure alone causes no very great 
disturbance if the parts can escape to one side. Henschen reports a 
case in which no corresponding homonymous loss of the field of vision 
was produced by a tumor in the immediate vicinity of the optic 
radiations, upon which it must have exercised pressure. 



DISEASES OF THE NERVOUS SYSTEM. 139 

A tumor may also grow mainly in one direction while it advances, 
very little or not at all in the opposite direction. 

In other cases of rapidly growing tumors which invade neigh- 
boring parts, irritate and then destroy the tissues, there are much 
more extensive symptoms than would correspond solely to the loca- 
tion of the tumor. The remote effects may be manifested over an 
entire hemisphere, even over both hemispheres. The latter appear 
usually as symptoms of cerebral compression, viz., headache, vomit- 
ing, dulness, slow pulse, somnolence, dilatation of the pupils, etc. 

Not infrequently the remote effects are apparently paradoxical. 
According to Jastrowitz, unilateral and bilateral paralyses of the 
ocular muscles, especially of the abducens, are frequent. According 
to Gowers the abducens is especially exposed to pressure on account 
of its long course in the skull. After artificial increase of pressure 
in the skull Wernicke found evidences of pressure on the opposite 
motor oculi nerve. Oppenheim reports a case of tumor of the right 
frontal lobe with paralysis of the left abducens. 

The tumor is often surrounded by a zone of irritated tissue which 
is destroyed at a later period (irritative symptoms passing into 
paralysis) . The varying amount of blood in the tumor and adjacent 
parts causes increase and diminution of the pressure symptoms, but 
as a general thing they increase and finally become constant. 
Hemorrhages and softenings in the tumor and surrounding parts 
may develop and give rise to corresponding symptoms. Among the 
irritative symptoms due to the growth of the tumor are the frequent 
convulsions and epileptiform attacks, especially if they are unilateral 
(Jacksonian epilepsy) and terminate in paralysis. The irritative^ 
symptoms also include the not infrequent conjugate deviation of the 
head and eyes. 

To this category also belong the paroxysmal attacks of bilateral 
blindness, which begin with concentric narrowing of the field of 
vision and must be regarded as rudimentary epileptic seizures. They 
usually last only a few minutes, but may be repeated a number of 
times in a single day. Hirschberg observed cases in which the field 
of vision was constantly contracting and enlarging for half an hour 
to an hour {Neur. CentralbL, 1891, p. 449). 



140 THE EYE IN RELATION TO DISEASE. 

The growth of a tumor can be best followed in the region of the 
muscle nuclei and at the base of the brain. Tumors in the latter 
locality, particularly in the region of the chiasm, the petrous portion 
of the temporal bone and the sphenoid, often produce unilateral or 
bilateral exophthalmus from pressure on the cavernous sinus and 
ophthalmic vein, particularly if the tumor grows into the orbit 
itself. The ophthalmoscope often reveals single or double optic 
neuritis, which passes into partial or complete atrophy. Thromboses 
of the veins of the orbit and the retina may also be produced. 
In such cases, however, the symptoms may also be due to indepen- 
dent metastases in the orbit. 

In tumors of the frontal lobes, unilateral neuritis of the optic 
nerve or choked disc may be produced by direct implication of the 
nerve, but this is only observed in a minority of cases. 

The local symptoms in tumors have much less diagnostic value 
than in cases of softening, because they often originate in parts 
which are quite remote from the tumor and which may be found en- 
tirely normal on autopsy. Moreover, such local symptoms may or 
may not be present in similar tumors of the same region. 

If the tractus, chiasm, or optic nerve is directly implicated, a 
corresponding disturbance of vision develops with partial or com- 
plete atrophy of the papilla, visible with the ophthalmoscope. The 
atrophy may be preceded by irritative symptoms (neuritis) , but this 
is rare. The anatomically visible compression or flattening of the 
parts does not always correspond to the clinical disturbance of vision. 

We sometimes find a perfectly flat optic nerve with almost normal 
function. On the other hand there may be very great disturbance of 
function with very slight change of shape. It is evident that the pres- 
sure per 56 is less important than the resulting circulatory and nutri- 
tive disturbances and the occurrence of inflammatory changes which 
spread from the tumor into neighboring parts. 

Choked disc is much the most important sign in the diagnosis 
of a tumor. It usually begins quite suddenly, although previously 
the fundus had been perfectly normal. Within about twenty-four 
hours — not infrequently after decided remission of previously exist- 
ing pain in the head — a swelling of the papilla rapidly develops ; it 



DISEASES OF THE NERVOUS SYSTEM. 141 

may increase to three times the normal diameter, and projects more 
or less into the interior of the eye. A difference of refraction 
amounting to 4 or 5 dioptrics between the fundus and the top of 
the elevation is not rare. At the same time the originally hyper- 
aemic papilla becomes pale, often glassy in appearance, the vessels 
are sinuous in correspondence with the protrusion, and the veins are 
often dilated. The border of the elevation often has a bluish or 
bluish-violet color. In one case of very recent choked disc in a boy, 
I noticed several concentric rings of reflex around the papilla, evi- 
dently due to the formation of folds in the retina which had been 
pushed aside by the swollen papilla. After a variable length of time 
the papilla again becomes redder. Small, usually linear hemorrhages 
develop upon it and in its vicinity, and also whitish or yellowish 
degenerative foci (similar to those in Bright's disease) . The tissue 
of the papilla usually grows more opaque and the redness then in- 
creases, but this is by no means always the case. 

At a later period the middle of the papilla fades and hemorrhages 
and degenerative foci are absorbed ; it sinks, and its size is gradually 
reduced to the normal. The originally blurred border become dis- 
tinct, and finally the papilla has a uniform chalky-white color 
without visible details on its surface. Only the sinuosity of the 
vessels near the previously swollen disc enables us to recognize that 
the atrophic discoloration (white atrophy) has followed a choked 
disc. Not infrequently a fringe of pigment is found around the disc, 
and indicates the circumference of the former swelling. It is only 
rarely, and usually not in tumors, that the papilla resumes its normal 
appearance. In such cases swelling predominates, and the opacity 
of the tissues is almost or entirely absent. I have seen a case of this 
kind in which the sinuosity of the vessels near the circumference of 
the former swelling was the sole indication of the previous unilateral 
choked disc. Central vision and the field of vision were normal, but 
green blindness remained in this eye. 

At least six or eight weeks, often a longer period, elapse before the 
changes visible with the ophthalmoscope have run their course. The 
papilla often remains for weeks in a certain middle stage between 
swelling and atrophy. 



142 THE EYE IN RELATION TO DISEASE. 

As a rule disturbance of vision is observed, but it is not neces- 
sarily present in simple choked disc. [Mathewson reports a case of 
three years' duration — Trans. Fifth Internat. Ophth. Congress, 1876, 
p. 63.— Ed.] Various degrees of impairment of central vision, con- 
centric and sector-shaped narrowing of the field of vision, central 
and peripheral scotomata passing even into complete blindness, color 
disturbances, etc., may be present from the beginning or during the 
progress of a choked disc, and may continue after it has run its 
course. The ophthalmoscopic appearances and the disturbances of 
sight are often grossly disproportionate to one another. 

As the causal process is progressive the disturbance of vision 
usually has a progressive character, though often interrupted by 
more or less complete intermissions. Not all the disorders of vision 
in tumors of the brain are the result of choked disc, as the visual 
fibres may also be directly injured in any part of their course. More- 
over, disorders of sight also occur in tumors of the brain without 
any anatomical findings. 

In the large majority of cases choked disc is bilateral, although 
it is not always equal in degree on the two sides. When unilateral, 
it is usually situated on the side of the tumor, the latter being then 
located in the anterior part of the brain. It also frequently happens 
that the choked disc occurs at an earlier period or in a more marked 
degree upon the side of the tumor. 

Typical choked disc is almost the most important symptom in the 
diagnosis of brain tumor of whatever kind or wherever situated. 
Sooner or later, often shortly before death, it is added to the 
other symptoms in a very large percentage of cases (two-thirds or 
more) . It is not one of the early symptoms, but I remember a case 
in which, from finding a double choked disc, I made a diagnosis of 
tumor of the brain in a patient who had complained merely of fre- 
quent dull headache and occasional vomiting, and had been treated 
for disease of the stomach. In a few days the autopsy showed the 
correctness of the diagnosis (glioma of the cerebellum) . 

Choked disc does not occur with equal frequency in tumors of the 
different parts of the brain. It is said to be somewhat less frequent 
in tumors of the frontal lobes, more frequent in those of the cerebel- 



DISEASES OF THE NERVOUS SYSTEM. 143 

lum and adjacent parts. It also occurs in tumors of the spinal 
cord, though less constantly. 

Choked disc is also observed exceptionally in other affections, for 
example, cerebral hemorrhages, abscesses, and many other diseases. 
Entirely similar appearances are found occasionally in albuminuria, 
diabetes, leukaemia, after profuse hemorrhages, etc. However, this 
hardly impairs the importance of choked disc in the diagnosis of 
brain tumor. 

Anatomical examination shows very constantly an ampulliform 
swelling of the optic nerve, immediately behind the sclera. It is 
due to the accumulation of fluid within the sheaths of the nerve. 
This is often absent in the " atrophic" stage. The ampulla also oc- 
curs independently of choked disc, for example, in meningitis (Leber, 
Broadbent, vide " Jahresb. f. Aug.," 1872, p. 359). 

At the start, the microscope shows merely oedema of the ocular 
extremity of the nerve, but finally hemorrhages, swollen nerve fibres, 
etc., are found. The calibre of the papillary vessels varies. These 
changes are confined to the ocular end of the nerve ; posteriorly no 
abnormal changes are found, either in the nerve itself or in its 
sheaths. 

After a while proliferative processes develop in the perineurium 
and interstitial connective tissue, and finally there may even be fatty 
degeneration and destruction of the nerve fibres. Posteriorly the 
nerve exhibits no changes, with the exception of ascending atrophy 
which may develop at a later period. This atrophy, which is attended 
by the presence of granular cells and amyloid corpuscles, may be fol- 
lowed occasionally into the chiasm and farther back. The ampulla 
sometimes disappears and the sheath exhibits folds. In other cases, 
especially when pronounced inflammatory changes in the nerve have 
been present, proliferation of connective tissue takes place (Fuerstner, 
Berl. kl. Woch., 25, II, 1889) or endothelial proliferations project 
into the inter vaginal spaces. 

In certain cases distinct inflammatory changes (cellular infiltra- 
tion) occur at the ocular end of the nerve, and are seen with the 
ophthalmoscope as increased cloudiness of the swollen papilla. We 
are therefore justified in distinguishing pure choked disc and 



144 THE EYE IN RELATION TO DISEASE. 

choked neuritis. Pure choked disc or simple oedema of the ocular 
end of the nerve very probahly causes no direct disturbance of 
vision, but only indirect disorders from the circulatory changes 
v^hich are due to the pressure on the vessels and the consequent im*- 
paired nutrition. In inflammatory processes of the papilla (choked 
neuritis) disturbance of vision is more apt to occur, although even 
then the nerve fibres are affected secondarily, inasmuch as the 
process is essentially interstitial. 

Few writers distinguish between choked disc and choked (ob- 
structive) neuritis. In very many cases a distinction is not even 
made between choked disc and neuritis. Thus, the English writers 
often use the term optic neuritis in undoubted cases, of choked disc. 

Graefe's original opinion that choked disc is due to compression 
of the cavernous sinus was abandoned as soon as it was demon- 
strated (Sesemann) that the outflow from the ophthalmic vein takes 
place in great part through the posterior facial vein. Certain other 
theories, for example that of Loring, who believed that the condi- 
tion was due to the circulatory and trophic influence of trigeminal 
irritation, have also been discarded. At the present time two 
theories are still maintained, viz., the purely mechanical, transport 
theory (Manz) and the inflammatory theory (Leber) . According to 
Manz (Arch. f. Ophth., XVI, p. 265), choked disc arises from the 
entrance of fluid into the subdural and subpial spaces of the optic 
nerve from the corresponding spaces of the brain, and this com- 
presses the intraocular extremity of the optic nerve. He made ex- 
periments by injections of warm fluid into the cavity. According 
to Leber the tumor causes secretory inflammation and dropsy of the 
cerebral ventricles; their products act in the intervaginal space 
as an inflammatory irritant and give rise to the choked disc. 
Similar views are expressed by Leber's pupil, Deutschmann, who 
produced typical choked disc, of course with pronounced inflamma- 
tory "findings," by the introduction of tubercular material into the 
cranial cavity. 

Anatomical examinations in man prove indubitably that the 
choked disc of tumor of the brain begins as a pure oedema of the 
intraocular end of the nerve, without any signs of inflammation. 



DISEASES OF THE NERVOUS SYSTEM. 145 

At a later period interstitial inflammatory changes may be found in 
the specimen, but in some cases such changes are absent at all stages. 
In late stages we usually find only secondary atrophic processes. 
What argument is furnished by the introduction of tubercular matter 
into the cranium when compared with numerous accurate anatomical 
examinations in the human subject? In the former event purulent 
tubercular meningitis develops and, as happens so often, leads to 
true optic neuritis, which may be associated with a certain degree of 
swelling. Such experiments prove nothing whatever with regard to 
typical choked disc in brain tiunors. If the theory were true, inflam- 
matory appearances would necessarily be found in the orbital and 
intracranial parts of the sheaths of the nerve, and this does not hap- 
pen. Nor does the transport theory explain all the phenomena. 
According to Ulrich the stasis in the ventricles of the brain extends 
directly to the lymph spaces of the optic nerve without the agency 
of its vaginal spaces, and produces oedema of the optic nerve, which 
leads to choked disc from interference with circulation. CEdema 
of the trunk of the nerve occurs, for example, in tubercular menin- 
gitis, without choked disc. 

As a rule, however, oedema of the optic nerve is not found farther 
back in the orbit in typical choked disc, although it does occur occa- 
sionally. 

Normally there is a centripetal current of fluid from the eye to 
the brain within both the nerve and its sheaths, as I can experiment- 
ally demonstrate. If this is abolished by increased pressure within 
the cranium, stasis and oedema must develop. They will become 
evident, (1) in the optic nerve outside of the cranial cavity where it 
is not inclosed in a closely fltting sheath, i.e.^ at the intracular ex- 
tremity (choked disc) , and (2) within the vaginal spaces, where the 
external sheath is thinnest and most yielding, i.e., immediately be- 
hind the eye (ampulla) . The latter, however, requires a somewhat 
increased pressure. Hence, choked disc may occur without an 
ampulla. The development of choked disc merely requires simple 
stasis ; the " transport" of fluid from the cranial cavity is not neces- 
sary. 

This simple oedema of the papilla does not give rise to a disturb- 
10 



146 THE EYE IN RELATION TO DISEASE. 

ance of vision, in the absence of complications; it may be quite 
stationary for a long time and disappear without leaving a trace. 
This hardly ever occurs, however, in progressive tumors. With the 
increase in pressure intracranial fluid will enter the vaginal sheaths 
and will produce the ampulla. In intracranial hemorrhages or 
purulent meningitis this entrance of fluid has been demonstrated 
anatomically. Even then the fluid does not necessarily produce 
inflammation, because nutritive disturbances and destruction of tis- 
sue may result from the increased pressure alone (indirectly through 
the influence on the vessels !) . 

As a general thing, however, inflammation does result. Growing 
tumors, especially malignant ones, excrete irritating and inflam- 
matory substances, as is shown by the surrounding zone of reactive 
inflammation. These substances are also diffused in the cerebro- 
spinal fluid, especially the subarachnoid fluid, and enter the sheath 
of the optic nerve. They will produce their effect where the oedema 
develops most readily, ^.e., at the ocular extremity of the nerve. It is 
difficult, however, to understand why diffuse inflammations of the 
cerebral meninges do not develop, unless the preceding oedema of the 
end of the nerve is regarded as a predisposing factor. 

The affection of the end of the optic nerve in tumor of the brain 
is due, accordingly, to stasis from inhibition of the natural outflow 
(oedema of the papilla), to mechanical entrance of fluid into the 
sheaths of the nerve under increased pressure (the ampulla is the 
result of this factor) , and to more or less intense inflammatory phe- 
nomena which may, however, be entirely absent. 

In this way we can explain the fact that unilateral choked disc 
may result from intracranial (at the optic foramen) or intraorbital 
compression of the optic nerve. 

In cases of tumor of the brain in which sudden disturbance of 
vision sets in, after the subsidence of other symptoms (headache) , 
and fully developed choked disc is found, we must assume that oedema 
of the entrance of the optic nerve had already existed and that the 
increased intracranial pressure suddenly overcame an obstacle in 
the sheaths of the nerves. This obstacle must have been situated in 
the region of the canalis opticus and probably acted like a valve. 



DISEASES OF THE NERVOUS SYSTEM. 147 

Simple neuritis, terminating in atrophy, is found less often than 
choked disc in cerebral tumors. It happens particularly in tumors 
of the frontal lobes, in which the growth is situated comparatively 
close to the optic nerve. The affection may be interpreted as a de- 
scending neuritis. When unilateral, it may possess local diagnostic 
value. (Among twenty-five cases of tumors of the cerebrum Op- 
penheim {Arch. f. Psych, u. Nervenh., XXI and XXXII) observed 
typical choked disc fourteen times, neuritis five times, and hyper- 
semia of the papilla once) . 

More or less complete unilateral or bilateral atrophy of the 
nerve, with impaired vision, but unattended by inflammatory 
phenomena, may also occur. In such cases there is probably injury 
of optic tracts somewhere up to, and including, the primary optic 
centres. 

In very many cases, therefore, the ophthalmoscope furnishes a 
definite starting-point for the diagnoses. Cases have been observed, 
however, in which there were pronounced general tumor symptoms 
with double choked disc, but in which no tumor was found at the 
autopsy. On the other hand, choked disc may be absent in very 
large tumors, although we are unable to offer a sufficient reason for 
this peculiarity. 

Bruns {Bei^l. kl. Woch., 1886, ISTos. 21, 22) lays stress upon the 
absence of choked disc in tumors of the corpus callosum. 

When other symptoms are observed, the existence of double 
choked disc renders the diagnosis of tumor extremely probable. The 
location of the growth must be decided by the local symptoms, al- 
though these may vary greatly in tumors of the same region. Espe- 
cial importance attaches to progressive irritative symptoms which 
subsequently pass into paralysis, if the order of succession indicates 
a definite part of the brain. 

The character of the tumor can only be decided in connection 
v/ith all the other clinical symptoms. 

Aneurisms of the cerebral arteries are of frequent occurrence. 
They are small and give rise to no special symptoms, apart from 
those of the causal disease of the vessels, which is usually widespread. 
They may give rise to hemorrhage or thrombosis. 



148 THE EYE IN RELATION TO DISEASE. 

The larger aneurisms are situated most frequently on the carotid 
and its branches. Special symptoms are commonly produced only 
after the aneurism has attained about the size of a hazelnut, and 
these correspond exactly to those of a tumor. 

Aneurisms of the carotid within the skull usually cause paralysis 
of the nerves of the ocular muscles which pass alongside of or 
through the cavernous sinus {vide Fig. 18). They exert a dele- 
terious action on the adjacent chiasm and optic nerve, with a cor- 
responding peripheral disorder of vision and secondary atrophy of 
the nerve. Unilateral pressure on the nerve may also give rise to 
unilateral choked disc. 

As a large part of the sympathetic fibres of the eye pass through 
the carotid plexus, the aneurisms produce oculo-pupillary symptoms, 
occasionally of an irritative but usually of a paralytic character 
(ptosis, myosis, and slight enophthalmus) . The vasomotor fibres to 
the face take their course along the external carotid. 

As the ophthalmic arterj^ is derived from the internal carotid, 
aneurisms of the latter not infrequently cause changes in the amount 
of blood in the retinal vessels. This may result in arterial thrombosis, 
and, if the central artery of the retina is affected, leads to loss of 
vision with the ophthalmoscopic appearances of embolism of the 
retina. 

In a case of sudden rupture of an aneurism of the anterior com- 
municating artery, Bellamy {Lancet^ 6, VII, 1889) found blood 
within the sheaths of the optic nerve and also in the meningeal 
spaces. 

A celebrated case is that reported by Weir Mitchell (Journ. of 
Nerv. and Ment. Dis. , 1889, p. 44) . A man aged forty-five years had 
suffered for five years from headache and disturbance of sight. The 
ocular muscles were normal. Both nasal halves of the retinae were 
entirely blind and there was atrophy of the nasal halves of the papil- 
lae (bitemporal hemianopsia) . Central vision was yV on both sides 
and fell to ^ before death, which occurred suddenly in coma. An 
aneurism as large as a lemon was found upon an abnormal commu- 
nicating branch between the carotids, which passed beneath the 
chiasm. The latter was divided in the median line from before back- 



DISEASES OF THE NERVOUS SYSTEM. 149 

ward and the sella turcica had been eroded. Two thin atrophic 
bundles of nerves (the uncrossed bundles of the optic nerves) were 
found in the place of the chiasm. This finding absolutely demon- 
strates the partial decussation of the optic nerves in the chiasm. 

Tumor of the dura mater may simulate meningitis, as in 
Unverricht's case {Centralbl. f. d. med. Wiss., 1888, p. 493), in 
which successive paralysis of aU the cerebral nerves and unilateral 
keratitis neuroparalytica developed. Metastases were found between 
the dura and the base of the skull; these occluded the foramina. 
The primary tumor was a round-cell sarcoma, the size of an apple, 
in the mediastinum. 

I have seen a metastasis between the dura and the left frontal 
bone, starting from a cancer of the stomach, which could not be 
diagnosed with certainty during life. The symptoms were those of 
a pachymeningitis hsemorrhagica, and the macroscopic appearances 
at the autopsy were very similar to this condition. A few days be- 
fore death the ophthalmoscope showed neuritis of the left optic nerve 
without notable impairment of vision, but with great photophobia. 

Nettleship {Ophth. Review, 1887, p. 57) describes post-neuritic 
atrophy of the optic nerve in a boy of twelve years, suffering from 
exostoses of the skull. 

Marchand {Vircli. Arch., Bd. 75, p. 404) reports a case in which 
multiple cysticerci of the surface of the brain gave rise for years to 
paroxysmal visual hallucinations ; later blindness developed suddenly 
in both eyes, and in two and one-half months the fatal termination 
occurred. Engler {Prag. med. Woch., 1888, No. 2) observed double 
choked disc without subjective disturbance of vision in a girl of 
twenty-three years who had numerous cysticerci of the subcutaneous 
cellular tissue and muscles, and who suffered from periodical head- 
aches, occasional parsesthesise, nausea and vomiting. Whether 
these symptoms were due to a cysticercus in the brain, must remain 
doubtful, inasmuch as no post-mortem examination was made. 

Tumors of the eye sometimes grow along the optic nerve into the 
skull and brain. This is particularly true of retinal gliomas, while 
choroidal sarcomata develop metastases usually in other parts, such 
as the liver, Ij-mphatic glands, etc. Tumors of the optic nerve and 



150 THE EYE IN RELATION TO DISEASE. 

other malignant tumors of the orbit may also proliferate into the 
cranial cavity, but such growths are rare. 

Meningitis. 

The eye is extensively involved in the different forms of meningitis 
(simple, epidemic, tubercular, acute and chronic; internal and ex- 
ternal hydrocephalus ; leptomeningitis and pachymeningitis) . Gen- 
eral eye symptoms are unimportant. During diffuse cerebral irri- 
tation the eye takes part in the general hypersesthesia by great 
photophobia and sensitiveness to light. When there is increased 
intracranial pressure, the pupils are dilated and react poorlj^, but 
there are numerous exceptions to this rule. 

Much more importance attaches to the local symptoms, which 
vary according as the meningitis affects the convexity or the base 
of the brain. 

In meningitis of the convexity, disturbance of the function of the 
visual cortex may give rise to double blindness in which the reac- 
tion of the pupils to light may remain intact and the ophthalmoscope 
show no changes. In such a diffuse disease it is only for a short 
time that the lesion will act upon one side alone (homonymous 
hemianopsia with intact pupillary reaction to light), although this 
is certainly not infrequent. If the process comes to a standstill, re- 
covery may occur. 

Conjugate deviation of the eyes may also appear. Jaccoud 
(" Jahresb. f. Aug.," 1879, p. 243) observed conjugate deviation to the 
right in purulent meningitis of the left hemisphere and congestion of 
the right hemisphere. As a temporary symptom conjugate deviation 
is not infrequent. 

Disturbances of vision are usually peripheral and due to changes 
at the base of the brain. These and other basal symptoms are among 
the most important diagnostic signs of basilar meningitis. 

The exudation at the base causes irritation and inflammation of 
the nerves imbedded in it. It is usually most abundant in the region 
of the chiasm. Hence we find a great variety of irritative and par- 
alytic symptoms in the province of the basal cerebral nerves, the ab- 
ducens, motor oculi, trochlearis and facial. Leichtenstern {Deutsch. 



DISEASES OF THE NERVOUS SYSTEM. 151 

med. Woch., 1885, 31), who reported twenty-nine cases of epidemic 
meningitis, found that the' abducens was attacked most frequently, 
the motor oculi very rarely (in the hydrocephalic stage there was 
slight bilateral ptosis in one case, weakness of an internus in one case, 
and inequality of the pupils in one case) . In tubercular meningitis 
the pupil is often dilated and very sluggish ; in the epidemic form, 
he observed this symptom in onl}' two cases. In one case there was 
isolated abducens paralysis, although all the nerves were imbedded 
in exudation and both motores oculorum nerves were very much 
reddened. In one patient, who was still conscious, there was paraly- 
sis of all the ocular muscles, including the levatores palpebrarum, 
but the reaction of the pupils to light was normal. Nystagmus was 
observed several times. 

Trigeminal hypersesthesise, parsesthesiae, and ansesthesise are quite 
frequent. Ansesthesise of the cornea may give rise to so-called neuro- 
paralytic keratitis, for example, Robinson {Lancet, 1880, II, p. 612), 
Spierer {Monatshl. /. Aug., 1891, p. 222). 

Spasms and paralyses have a peripheral character. Unless due 
to irritation of the cortex of the convexit}", they are not conjugate 
and associated, but affect individual nerves or parts of nerves and 
soon lead to permanent degeneration of nerve and muscle. 

The nerves of special sense, the acoustic, optic tract, chiasm and 
optic nerve are often imbedded in the more or less cellular exudation. 
At first this gives rise to irritative symptoms, later to destruction of 
the nerve with corresponding disorders of sight and hearing. After 
a while the ophthalmoscope shows more or less atrophic discolora- 
tion of the papilla. 

The optic nerve is often implicated directly. It and its sheaths 
take part in the inflammatory infiltration, and the ophthalmoscope 
shows the picture of optic neuritis, one of the most important aids 
in the diagnosis of meningitis. The optic nerve is more or less 
reddened, its borders obliterated, its tissue cloudy. The latter sign 
is the most important in the differentiation from simple hypersemia. 
Pronounced hypersemia of the vessels is not always visible. It is 
YQvj often present, however, and is made manifest by the fact that 
a large number of otherwise invisible little vessels become visible 



152 THE EYE IN RELATION TO DISEASE. 

upon the papilla. In many cases the location of the papilla can only 
be recognized by the entrance of the vessels. The papilla is not at all 
or very slightly prominent ; hemorrhages and exudations are com- 
paratively rare. 

A microscopic examination in this stage shows that the inter- 
vaginal space is not dilated, but the connective-tissue septa and the 
pial sheath are infiltrated with cells. This infiltration increases 
toward the' periphery. At the lamina cribrosa the impression is 
created as if the centrif ugally wandering cells had been filtered into 
that locality, and indeed this may be the actual anato mo-pathological 
occurrence. 

At a later period the papilla grows paler. It finally becomes as 
white as chalk, is sharply defined, and shows almost no details upon 
its surface. The vessels are more or less narrowed (post-neuritic 
atrophy). The findings are similar to those seen after a choked 
disc has run its course with marked infiammatory symptoms. In 
this stage the microscope shows connective-tissue increase in the 
nerve and more or less complete loss of nerve fibres. 

Optic neuritis in meningitis is generally bilateral, although it does 
not always appear at the same time on the two sides or with equal 
intensity. The termination in atrophy is usually observed only in 
those cases which do not prove fatal. 

The disorders of sight may vary greatly but are usually consider- 
able. They include impairment of vision, of the recognition of col- 
ors, concentric and sector-shaped narrowing of the field, central and 
peripheral scotomata, sometimes for colors alone, and even complete 
blindness. Complete restoration of sight is rare. Even if blindness 
does not ensue, there is usually more or less impairment of vision ; 
disorders of the color sense, defects of the field, and also defects of 
the other organs of special sense, particularly of hearing, remain. 

It is difficult to furnish definite statements concerning the fre- 
quency of optic neuritis in the different forms of meningitis, espe- 
cially as many writers include choked disc, choked neuritis, and 
neuritis under the latter term. But it is undoubtedly found in the 
majority of cases, although often not until a late period when the 
diagnosis has been assumed from other symptoms. When it appears 



DISEASES OF THE NERVOUS SYSTEM. 153 

at a comparatively early, period it may be of the greatest importance 
in excluding typhoid fever, pneumonia, etc. In the latter affections 
optic neuritis is extremely rare. 

In purulent meningitis the inflammation extends not infrequently 
through the superior orbital fissure to one or both orbits. We then 
find oedema of the conjunctiva (chemosis) , which may run its course 
without any further visible sign of inflammation and is occasionally 
one of the first symptoms. In other cases infiltration and sup- 
puration of the orbit set in with protrusion of the eye, oedema of the 
lids, etc. The oedema of the lids exhibits one feature which is char- 
acteristic of orbital suppuration, i.e., it ceases abruptly at the bony 
rim of the orbit. Notable disturbance of vision is not necessarily 
present even in orbital abscess, but it usually occurs sooner or later 
from implication of the optic nerve and may lead to permanent blind- 
ness. Interference with the movements of the eye in one or another 
direction is not uncommon. 

As a rule the inflammation extends into the orbit along the veins. 
Exceptions are sometimes observed, as in the following case reported 
by Hofmann {Neurol. Ce7itralbl., 1886, p. 357). After furunculosis 
of the neck meningitic symptoms developed, attended by violent head- 
aches and slowing of the pulse. The left eye was pushed forward, 
blind and immovable : there were ptosis, dilated pupils and choked 
disc. No pus was found on opening into the orbit, but the optic 
nerve was swollen to the size of the little finger, and pus was 
evacuated from the ampulla. After drainage recovery set in, but 
ptosis, blindness and atrophy of the optic nerve were left. 

A sero-plastic-purulent choroiditis is another frequent symptom 
during and after meningitis. It begins with ciliary injection, dis- 
coloration of the iris, distortion of the pupil and cloudiness of the 
fundus, the details of which can no longer be recognized, A yellowish 
hypopyon and a similar pupillary exudation not infrequently develop 
after a little while. There may be parenchymatous opacity of the 
cornea (by immigration from its borders) , but true suppuration is not 
often seen. Panophthalmitis with termination in suppuration and 
phthisis bulbi is also a comparatively rare symptom. Blindness usu- 
ally occurs at a very early period, and the eye is soft from the start. 



154 THE EYE IN RELATION TO DISEASE. 

At the end of a few weeks the ciliary injection, hypopyon and 
pupillary exudation commonly disappear, the cornea clears up, the 
iris is found superficially adherent to the lens, is usually lighter in 
color than that of the other eye, and later is distinctly atrophic ; the 
pupil remains irregular and immovable. The blindness is generally 
permanent, and it is only in mild, not fully developed cases that 
some visual power remains. 

The eye subsequently grows softer, becomes considerably smaller, 
and often appears quadrate under the pressure of the recti muscles. 
The lens may remain transparent for a long time and enable us to 
recognize in the vitreous a dense, whitish-yellow mass which often 
extends to the lens. In this exudation we often see new-formed ves- 
sels, also slight hemorrhages, so that occasionally it is hardly possi- 
ble to avoid mistaking it for glioma of the retina prior to its 
"glaucomatous stage." This is so much more apt to occur because 
both meningeal exudative choroiditis and glioma are prone to occur 
in children, and because the previous symptoms of meningitis have 
not been correctly interpreted. As the eye is always blind, the error 
in doing enucleation is not very disastrous, in view of the great 
malignancy of retinal glioma. Diagnosis is based upon a greater or 
less degree of probability, and the opposite mistake would be much 
more serious in its consequences. 

After the lapse of years calcifying cataract gradually develops, 
often also band-shaped keratitis with development of callosities and 
calcifications. 

As a rule the disease is unilateral. It occurs usually in simple 
meningitis of young children, but it may also appear at a late period, 
for example, during epidemics of meningitis. The disease may ap- 
pear at the onset of the meningitis or some weeks (six to eight) after 
the latter has subsided. Recoveries with fair or good sight do occur 
but are rare. Knapp (Zeitschr. /. Ohreiiheilk., XIV, p. 241) reports 
a case of bilateral deafness and exudative choroiditis after cerebro- 
spinal meningitis in a boy of six years. The left eye recovered, the 
right eye became phthisical. 

On anatomical examination of such cases it has been found that 
the optic nerve and its sheaths were free from inflammation (Modi, 



DISEASES OF THE NERVOUS SYSTEM. ] 55 

Wien. med. Wocli., 1880, No. 29; Oeller, Arch. /. Aug., YIII, p. 
357). Berlin assumes, accordingly, that orbital inflammations ex- 
fend from the cranial cavity solely through the medium of phlebitis 
of the ophthalmic vein (through the superior orbital fissure). The 
simplest hypothesis is that of a real metastasis, but this will not hold 
good for the cases in which meningitis and choroiditis are almost 
simultaneous in their onset. Here we must assume the coincident 
deposit of the same morbific substance in the pia mater and choroid. 
This theory is the more plausible in view of the fact that both struc- 
tures are developmentally alike. 

Bull (Jalir. f. Aug., 1873, p. 304) observed two rudimentary 
cases in epidemic meningitis. In one case there was swelling of the 
papilla with numerous yellowish, prominent patches in the choroid ; 
in the other case there was a coherent mass of choroidal exudation 
in the fundus. In the latter case atrophy of the optic nerve sub- 
sequently developed. There are also all degrees of transition to 
milder forms of choroiditis and cyclitis such as are observed fre- 
quently after typhoid affections, especially after relapsing fever. 

As the result of purulent meningitis following aural suppuration, 
Nettleship observed purulent choroiditis on the left side, and only 
neuritis on the right side. It seems as if, in such cases, neuritis alone 
develops when the chemical and not the living agents of inflam- 
mation enter the optic nerve and its sheaths. Purulent choroiditis 
develops in a discontinuous manner, although, as Hofmann's case 
shows, the direct extension of the process cannot be excluded in all 
cases. 

Purulent inflammations of the eye may be the starting-point for 
metastatic purulent meningitis. Occasionally it is merely a purulent 
conjunctivitis (Politzer, Jalir. f. Kinderheilk., 1870, p. 335), but 
usually it is a traumatic septic panophthalmitis with or without a 
foreign body in the eye. Some writers advise, though wrongly, 
against the enucleation of an eye affected by panophthalmitis. If, 
after the removal of such an eye (as a matter of course, under anti- 
sepsis), meningitis sets in, the operation was performed too late, 
because there is no doubt that the eye is the source of infection. 
Purulent meningitis also occurs in panophthalmitis without enuclea- 



156 THE EYE IN RELATION TO DISEASE. 

tion, for example, after cataract operation {Jahrb. f. Aug.^ 1888, 
p. 217). Kolland {ibid., 1885, p. 365) performed seventy enuclea- 
tions in panophthalmitis without meningitis, nor have I had a fatal 
result in numerous cases. [About forty fatal cases of meningitis 
after enucleation of the eye have been published, yet even with acute 
suppurative panophthalmitis as a frequent cause of enucleation 
(about 14 per cent), the ratio of death is about 1 in 4,000. See 
''Text-book of Diseases of the Eye," by Noyes, 1894, p. 545.— Ed.] 

In epidemic cerebro-spinal meningitis conjunctival catarrh often 
appears at the beginning. An important symptom is an early oede- 
ma of the conjunctiva, from extension of the inflammation in the or- 
bit along the veins and interference with the return flow, especially 
in the ophthalmic vein. 

According to Foerster {I.e., p. 105) deep subepithelial infiltrations 
of the cornea, which may be entirely reabsorbed, also occur in epi- 
demic cerebro-spinal meningitis. Among twenty-eight cases of the 
disease Jedrzejewicz {Jahrb. f. Aug., 1880, p. 249) found two 
cases of the above-described form of choroiditis. 

In tubercular meningitis the symptoms of simple meningitis are 
supplemented by those of tuberculosis of the eyeball or brain. While 
choked disc is very rare in pure meningitis (Bramwell, Jahr. f. 
Aug., 1879, p. 244; Panas, Eec. d'Ophth., 1886, p. 651), it is more 
frequent in the tubercular form, especially if the brain contains a 
solitary tubercle which per se gives rise to all the symptoms of a 
tumor. 

In the typhoid terminal stage of meningitis, as in all diseases 
which present a tj^phoid state, a desiccation keratitis is not infre- 
quently observed. On account of the imperfect closure of the lids 
and arrest of winking, the exposed parts of the cornea and conjunc- 
tiva desiccate and infectious inflammation develops beneath the crust. 
Cessation of the pupillary reaction to cutaneous irritants is said to 
be a terminal symptom, but it merely proves peripheral anaesthesia 
of the irritated parts of the integument. 

Senator {Charite Ann., XI, p. 248) saw nystagmus and iritis in 
meningitis. Gairdner and West {Jahrb. f. Aug., 1878, p. 241) 
report rapid alternation of myosis and mydriasis in tubercular 



DISEASES OF THE NERVOUS SYSTEM. 157 

meningitis. In several cases of basilar meningitis, Kahler {Prag. 
med. JVoch., 1887, No. 5) observed maximum dilatation of the 
pupil when the patient sat up; this disappeared on lying down. 

Bock {JVien. med. Woch., 23, XI, 1889) reported five cases of 
cataract after meningitis in persons in the thirties, which were 
cured b}' operation. The diagnosis of meningitis is by no means 
undisputed, and the connection between the two conditions appears 
obscure. Perhaps a part is played by the spasms which occur in 
the ciliary muscle and which might produce nutritive disturbances in 
the lens from interference with the circulation. It is a striking fact, 
however, that no other writer speaks of the development of cataract 
after meningitis — of course apart from the secondary form due to exu- 
dative choroiditis — although violent spasms are hardly ever absent 
in the more acute forms. 

In chronic hydrocephalus the symptoms of compression predomi- 
nate. Choked disc and choked neuritis and simple optic neuritis 
are observed not infrequentl3\ They are almost always bilateral and 
associated with marked disturbance of vision. They terminate in 
atrophy of the optic nerve and, as a rule, in blindness. Widely 
staring eyes (so-caUed "hunger for light") are often mentioned, but 
are common enough in blindness from any kind of total atrophy of 
the optic nerve. ISTystagmus is not uncommon. 

In one case of chronic leptomeningitis Veronese ( Wien. klin. 
Woch., 1889, No. 24) observed sudden blindness with normal ophthal- 
moscopic appearances, without any other disturbances of conscious- 
ness or motion. This was evidenth' a central visual disturbance in 
the cerebral cortex or the corona radiata. Subsequently two cerebral 
apoplexies occurred, and the fatal termination ensued one and a half 
years later. At the autopsy the optic nerve, chiasma, and tractus ap- 
peared normal, and purulent, bloody fluid was found in the lateral 
ventricles. 

The oft-mentioned affections of the optic nerve in deformities of 
the skull (Manz, Ber. d. Heidelb. ophth. Ges., 1889, p. 18; Yossius 
and Stood, Jahr. f Aug., 1884, p. 354; Michel, AfxJi. f. Heilk., 
1873, p. 39; Schneller, Jahr. f. Aug., 1881, p. 253) consist of more 
or less complete atrophy, usually after preceding neuritis, with 



158 THE EYE IN RELATION TO DISEASE. 

corresponding disturbance of vision. They are due to chronic men- 
ingitic changes which lead, on the one hand, to premature ossifica- 
tion of the cranial bones ; on the other hand, to constriction of one or 
both optic nerves at the optic foramen. Michel found, in such 
cases, endothelial proliferation into the constricted intervaginal spaces 
of the optic sheath. 

Circumscribed meningitis, of extra-uterine origin, must be re- 
garded as the cause of the large majority of cases of so-called heredi- 
tary affections of the optic nerve. They run their course as a neu- 
ritis with subsequent atrophy (usually partial, rarely complete) of the 
optic nerve. At the start we often find marked changes in vision, 
as nyctalopia, photophobia, color phantasms, etc. More or less im- 
pairment of sight, central or eccentric scotomata and other defects of 
the field, color disturbances, etc. ,^ are usually left (Leber, Arch. f. 
OpUh., XVIT, p. 249). Daae's cases {Jahr. /. Aug., 1870, p. 379) of 
frequent occurrence of hemianopsia in one family, or of progressive 
binasal hemianopsia, point to the region of the tractus and chiasm. 
In a typical case of hereditary disease of the optic nerve I found 
normal vision despite atrophic discoloration of the papilla, although 
green blindness was present. 

The presence of neuritis, however slight, and its slow course, dis- 
tinguish this disease from Graefe's retrobulbar neuritis with sudden 
blindness, with at first negative ophthalmoscopic findings and later 
atrophy of the papilla. 

Hemorrhagic pachymeningitis gives rise to the symptoms both 
of meningitis and of a growing tumor with periodical hemorrhages. 
As the disease is located mainly on the convexity, basal symptoms 
are usually absent. If the base of the brain be involved blood may 
be found within the sheaths of the optic nerve and meningitic changes 
will also appear at the base. Local cortical symptoms may be pro- 
duced, such as hemianopsia, conjugate deviation toward the side of 
the disease or toward the opposite side, ptosis, nystagmus, etc. 
These symptoms may disappear during the intervals between the 
attacks. Changes in the pupils also occur (Fuerstner, Arch. f. 
Psych, u. Nerv., VIII, 1, p. 1). 

When the pachymeningitis is located in the anterior part of the 



DISEASES OF THE NERVOUS SYSTEM. 159 

skull we may find unilateral or bilateral hypersemia and stasis of the 
optic nerve, neuritis, choked disc with or without impairment of 
sight, and choked neuritis, according as the symptoms of tumor or 
meningitis predominate. If the ophthalmoscopic appearances are 
unilateral they are usually found on the same side as the disease, or 
at least upon the side on which the lesion is most pronounced. 

We have already spoken (p. 149) of the possible hemorrhagic 
pachymeningitis with superficial metastatic tumors between the cra- 
nial bones and the dura mater. 

Insanity. 

We have already explained that so-called mental diseases must be 
regarded as extensive diffuse or localized affections of the frontal 
cortex, to which centripetal associative fibres pass from all directions 
and from which centrifugal fibres pass to all other parts of the brain. 

The purer the mental disease, the more strictly must the process 
be confined to the frontal lobes and the more completely will local 
symptoms be absent. On account of the frequent implication of 
other parts of the cortex, sensory and motor symptoms are also found 
in very manj' cases. 

The fact of the affection of other parts of the cerebral cortex, the 
presence of hallucinations of feeling (motor cortex) , hearing (acoustic 
cortex), sight (visual sphere), etc., is employed as an important prin- 
ciple of classification of mental diseases. It is well known that hal- 
lucinations of hearing are more frequent than those of sight, corre- 
sponding to the shorter distance between the temporal and frontal 
lobes. Such hallucinations may occur long before or during the dis- 
ease. In the first event the insanity begins at the moment when the 
hallucinations are no longer recognized as such but are regarded as 
objective. Illusions or false interpretations of actual objective sen- 
sory stimuli are also found in many cases. We will soon enter 
more in detail into different forms of unilateral hallucinations and 
illusions of sight. 

Numerous ophthalmoscopic examinations have been made in the 
insane (Jahresb. f. Aug., 1874, p. 428, and 1883, p. 338), but no 
constant findings have been discovered, apart from general paresis 



160 THE EYE IN RELATION TO DISEASE. 

and complications, such as tabes. Not even conditions of depression 
and exaltation furnish corresponding ophthalmoscopic appearances. 
The frequent injection of the conjunctiva, often amounting to con- 
junctivitis, in maniacal and excited patients is a result of this con- 
dition and of the insomnia rather than a direct equivalent of con- 
gestion of the cerebral cortex. Laudenbach and Bennett's statistics 
{N. Y. Journ. of New. and Ment. Dis., 1886, No. 13) of the oph- 
thalmoscopic appearances in 707 insane showed that no constant 
findings correspond to any definite form of insanity. Whenever a 
demonstrable affection of the eye is present — apart perhaps from 
hypersemia or anaemia of the fundus — it is always due to some ma- 
terial cause such as tabes, sclerotic foci, syphilis, albuminuria, etc., 
in the course of which insanity develops from involvement of the 
frontal lobes. 

Occasional findings of all kinds have been reported. According to 
Manz {Berl. kl. Woch., 1884, No. 50), the insane often exhibit con- 
genital anomalies of the eye, such as different colors of the iris of 
one or both eyes, accumulations of pigment in the choroid and retina, 
partial poverty of pigment, albinism, unusual shape of the pupils, 
abnormalities in the origin and course of the retinal vessels, etc. 
These conditions are probably signs of degeneration. 

According toRaehlmanu (Volkmann's Vortraege, No. 128), mani- 
acal patients often have enlarged pupils ; narrow pupils are character- 
istic of diminution of the cortical functions. This may be true as a 
general thing, but exceptions to the rule are very frequent. 

Injuries to the eye are not uncommon in insanity. The patient 
may gouge out one or both eyes, pull out the lashes, place sand and 
other articles into the conjunctival sac, etc. 

Psychoses also develop not infrequently after diseases of the eye, 
and especially after operations upon the organ. This occurs almost 
always in predisposed individuals (heredity, alcoholism, etc.), in 
whom the operation acts as an exciting cause. Repetitions may 
happen in successive operations on the eye. 

Among thirty-one cases of post-operative insanity Frankl- 
Hochwart {Jahrb. f. Psych., IX, 1 and 2) distinguished the follow- 
ing forms: a. Psychoses with hallucinations (without alcoholic: 



DISEASE^ OF THE NERVOUS SYSTEM. 161 

causation), 15 cases. In 6 it began in the first twenty-four hours; 
in 9 cases after an interval of from two days to three weeks. The 
condition consisted of frightful hallucinations and terror ; confusion 
was present almost constantly but was not always very pronounced. 
In 4 cases recovery occurred in a few days, in the others the course was 
a protracted one. h. Simple confusion in old people, senile condi- 
tions of excitement with no knowledge of the surroundings, 6 cases. 
Three of these rapidly improved, the other three terminated in de- 
mentia, c. Psychoses in alcoholics, viz., delirium, 7 cases. They 
began one to two days after the operation, usually at an earlier period 
than in non-alcoholics ; they ran a rapid course and soon terminated 
in recovery, d. Psychoses in marantic individuals, mental con- 
fusion from irritation, 3 cases. All proved fatal. 

The greater frequency of mental disturbances after operations on 
the eye than after other operations is due in part to the absolute rest, 
darkness and seclusion with closed eyes which are often required. 
These favor the occurrence of hallucinations and may thus arouse a 
latent mental affection in a predisposed individual. Some part is also 
played, at times, by the use of atropine which may give rise to 
hallucinations, epecially of sight. Of course the psychoses may also 
develop independently of the use of atropine. 

Valude {Ann. d'OcuL, 115, p. 212) observed in a woman of sixty- 
five years a maniacal attack foUow an iridectomy' in which atropine 
had not been employed ; it was relieved by the removal of the ban- 
dage. Parinaud (ibid.) reported a case of aphasia after a cataract 
operation; right hemiplegia developed soon afterward. Here the 
operation on the eye and the attendant excitement were the exciting 
cause of a cerebral hemorrhage. 

On the other hand Moulton (Ann. d^Ocul., Nov., 1891) claims to 
have cured a melancholic patient, aged forty years, by the removal 
of an eyeball which had been phthisical since the age of six years. 

An interesting observation was made by Soltmann {Neur. Cen- 
tralbl., 1890, p. 749). Children who are requested to write with the 
left hand usually employ the ordinary script, but in a slow and awk- 
ward manner. A small number, however, write backhanded, i.e., 

from right to left; these individuals suffered from a psychopathic 
11 



162 THE EYE IN RELATION TO DISEASE. 

hereditary taint. Deaf-mutes practise "mirror writing" when the 
deafness has been acquired in utero or in infancy, and ordinary 
writing when the deafness is acquired in later life. This is also true 
with regard to the blind. Of 16 imbecile children 13 employed 
"mirror- writing." Soltmann explains this fact on the ground that 
the control of the left hemisphere over writing is lacking, but this 
explanation does not seem to us to be sufficient. Perhaps it happens 
that one hemisphere does not, as is usually the case, acquire a more 
marked controlling influence over the function of writing. 

Hallucinations may be of various kinds (Mendel, Berl. kl. Woch., 
1890, 26, 27). There may be associate sensory impressions (photisms 
in the visual organ, phonisms in the auditory organ) ; for example, 
audible sounds produce a sensation of color. High-pitched sounds 
usually evoke light colors, low-pitched sounds dark colors, but the 
greatest individual differences are observed. Occasionally definite 
olfactory or gustatory impressions also produce the sensation of color ; 
for example, the smell and taste of vinegar produce red vision 
{olfaction et gustation coloree, olfactory and gustatory photisms) . 
In like manner the perception of color may be roused by the sight 
of certain numbers, letters, etc. This is said to occur particularly 
in hysterical psychoses, melancholia, and paranoia. Analogous 
associated sensations also occur in all the other special senses. 

Protracted after-sensations may be experienced after great mental 
excitement, the administration of cannabis indica, .and at the begin- 
ning of insanity (Mendel). 

Subjective visual sensations may be peripheral, as, for example, the 
phantasms of fire and sparks in inflammatory diseases and congestions 
of the optic nerve, retina and choroid, the yellow vision of san- 
tonin poisoning, etc. They are distinguished from central hallucina- 
tions and illusions in that the latter are false judgments about real 
sensorial phenomena. Hallucinations are either simple and elemen- 
tary, such as fire, colors, lightning, etc., or compound, such as the 
vision of shapes, animals, processions, either in a shadowy or 
perfectly distinct manner. In hallucinations of the muscular sense 
in the ocular muscles, the subjective visual impressions undergo 
movement, enlargement or diminution in size. 



DISEASES OF THE NERVOUS SYSTEM. 163 

Such a condition may lead to a refusal to take food; for example, 
in a lunatic who saw everything enlarged to an enormous extent and 
was frightened by the tremendous size of the articles of food {Neurol. 
Centralbl., 1888, p. 445). Illusions include those conditions in which 
the patient recognizes acquaintances in every one (delirium palin- 
gnosticum), or sees everything changed (delirium metabolicum), even 
his own shape, as in hypochondriasis, etc. Entoptic phenomena or 
the central scotoma of alcoholics may also give rise to illusions. 
Hallucinations and illusions are sometimes seen only when the eyes 
are open, sometimes when they are closed. 

Several senses are often affected at the same time. The hallucina- 
tions may be unilateral or different on the two sides ; for example, a 
man is seen on the right side, a woman on the left side. Bilateral 
hallucinations may become unilateral, and vice versa. 

Hallucinations are rare in focal diseases ; it is said that they are 
then more apt to be elementary. Bennet's epileptic patient, who had 
a lesion in the angular gyrus, had red vision as an aura. In a paretic 
dement with unusuall}' prominent visual hallucinations, Mendel 
{Neur. Centralhl., 1882, No. 58) found a remarkable amount of 
disease in the occipital lobes. The presence of visual hallucinations 
proves that the visual cortex is still performing its function. Hence 
if a defect in the visual field is cortical in origin, this is shown by 
the hallucinations, ^.e., the latter do not appear within the province 
of the defect in the field. Pick has observed a case of this kind. 
If both visual spheres are destroyed hallucinations of sight are no 
longer possible. 

Hallucinations have been observed in a child of fifteen months 
(stramonium poisoning). 

The main' causes of hallucinations are conditions of weakness, 
inanition, the period between waking and sleeping, many poisons 
(alcohol, cannabis indica, opium, stramonium, belladonna, santonin, 
etc.), hysteria and hystero-epilepsy, hypochondriasis, all the psy- 
choses with the exception of idiocy. 

The origin of visual hallucinations is direct or indirect irritation 
of one or both visual spheres, as a result of which the visual cortex, 
as well as the associated parts of the cortex (frontal lobes) , experiences 



164 THE EYE IN RELATION TO DISEASE. 

the same changes as if the visual impression corresponding to the 
hallucinations had been conveyed from the retina. 

According to Fere {Rev. de Med., 1890, p. 758) the pupils contract 
or dilate in visual hallucinations according as the apparent objects 
approach or move farther away. This shows that the visual 
cortex is also centripetally (motorially) active. Manifestly corre- 
sponding (cortical) convergence and accommodation take place. It is 
well known that conjugate deviation of the head and eyes toward 
the situation of the apparent object takes place very often. It occurs 
when the hallucinations are not situated at the point of fixation but 
in the periphery of the field of vision. 

Paretic Dementia. 

In paretic dementia eye symptoms are important. They possess 
great diagnostic and therefore prognostic significance because they 
often occur at an early period or supplement other doubtful symptoms. 

They consist, apart from certain trophic or vasomotor disorders, of 
disturbances of sight with or without ophthalmoscopic findings, or, 
more commonly, of disorders of the ocular muscles. 

The peripheral disorders of vision, in which ophthalmoscopic 
changes appear sooner or later, are not characteristic of the disease. 
There is usually a simple gray atrophy of the optic nerve, which is 
observed more frequently in tabes. It affects one or both eyes and 
leads to gradual impairment, concentric narrowing of the field, inter- 
ference with color-conduction, and in the end usually terminates in 
complete blindness. One difference from tabetic atrophy is the fact 
that there is often a slight preliminary cloudiness of the papilla and 
the adjacent parts of the retina, which does not lead necessarily 
to atrophy of the nerve. Uhthoff (Ber. d. Heidelb. ophth. Ges., 
1883) found this cloudiness in 28 per cent of the cases of paresis, 
Siemerling in only 8 per cent. This change in the fundus points to 
an inflammatory condition, however mild it may be, and other signs 
of the same character are not infrequent, viz., hypersemia of the 
retina, neuritis of the optic nerve, retinitis, etc. 

Klein (Wien. med. Presse, 1877, No. 3) observed 2 cases of 
atrophy of the optic nerve among 42 cases of paresis (nearly 5 per 



DISEASES OF THE NERVOUS SYSTEM. 165 

cent) ; Uhthoff (I.e.) found 8f per cent among 150 cases; Siemerling 
{Charite Ann., XI, p. 339) observed it 9 times among 151 cases (6 
per cent) . 

Unlike the ordinary form of atrophy with concentric narrowing 
of the field, Hirschberg {Berl. kl. Woch., 1883, JSTo. 39) reports a case 
which began as a progressive central scotoma, while the boundaries 
of the field and color perception at the periphery were normal. 
Boediker {Neurol. Centralhl., 1891, p. 187) has published a similar 
case. This finding warrants us in inferring, with a certain degree 
of probability, neuritic processes in the optic nerve. In such a lesion 
this disorder of vision is very frequent, as in the " axial" neuritis of 
so-called toxic amblyopia. 

Atrophy of the optic nerve is usually a late symptom of progressive 
paralysis, but it may also occur at an early period or even precede the 
mental disturbance (Wigleworth and Bickerton Brit. Med. Journ., 
21, IX, 90). Optic atrophy may be the sole eye symptom, but it is 
usually associated with others, especially with disorders of the ocular 
muscles. 

Among the less frequent ophthalmoscopic findings Siemerling (Z. c. ) 
reports slight optic neuritis in 2 per cent of the cases. Uhthoff and 
Moeli (I.e. ) found, among 150 cases, 3 cases of hypersemia of the 
papilla without pronounced opacity, 1 case of retinal hemorrhage 
and 2 cases of spindle-shaped dilatation of a small artery near the 
papilla. The latter condition reminds us of Klein's retinitis para- 
lytica, which he observed 18 times among 42 cases. In addition to 
opacity of the retina the arteries, more rarely the veins, exhibit 
spindle-shaped dilatations, often two or three in the course of the 
same vessel. These appearances have also been observed, however, 
in other cerebral diseases. Klein also foimd -i cases of retinitis, 1 of 
hypersemia of the fundus and 1 of choked disc. 

Among the central disorders of vision hallucinations are very com- 
mon during the course of the disease and often present at the start. 
In one case, in which they were especially striking, Mendel found 
at the autopsy an unusual amount of disease in the cortex and pi a 
mater of the occipital lobe. The hallucinations of sight may also be 
unilateral. 



166 THE EYE IN RELATION TO DISEASE. 

Homonymous hemianopsia, paroxysmal or permanent, is also 
observed ; sometimes it occurs in succession on the two sides and then 
it leads to complete cortical blindness. In one case of this kind 
Stenger (Arch. f. Psych, u. Nerv., XIII, 1, p. 218) found pronounced 
atrophy of the occipital lobes. Hemianopsia is often associated with 
hemiansesthesia or cortical paralyses. 

Psychical blindness also occurs with comparative frequency; it 
may be paroxysmal, lasting for days and then disappearing. It is 
always temporary; but diminution of sight and finally blindness 
usually develop at an early period. 

Riegel has investigated the disorders of reaction in progressive 
paralysis, and the results may be found in various Wurzburg theses 
(Rabbas, 1884; Kirn, 1887; Kraemer, 1888. The higher grades of 
such disorders among the insane are found only in paralytics, but 
are not constant. The characteristics are : a large number of " slips 
of the tongue," which every one makes occasionally, repetition of 
certain words and syllables, substitution of words which are not 
related in sense, sound or print, foreign-sounding words, a senseless 
gibberish of words, and usually the inability to recognize what has 
been falsely read. Another characteristic appears to be the frequency 
with which particular words are employed in all possible com- 
binations. 

Riegel regards these disorders as allied to aphasia and Berlin 
expresses a similar opinion. The latter assumes the " reading centre" 
to lie in the cortex in the vicinity of the third frontal convolution, 
the superior parietal gyrus, angular gyrus and the upper temporal 
convolution. These are regions of the cortex beneath which run the 
associative fibres between the occipital cortex and the motor speech 
centre. The disorders of reading in progressive paresis are evidently 
due to lesion of the motor speech centre and its associations with the 
higher frontal cortex, and also to disturbance of the associative con- 
nection of the visual sphere with the cortical regions just mentioned. 

Tlie most important and characteristic eye S5^mptoms of progres- 
sive paralysis are the muscular disorders. They may affect all the 
muscles of the eyes or onlj^ single ones. Anatomically these affec- 
tions are internuclear (reflex rigidity of the pupil) or nuclear in char- 



DISEASES OF THE NERVOUS SYSTEM. 167 

acter, or they involve the nerve roots or even the peripheral nerves 
themselves. Not even a lesion of the nerve terminations or the 
muscles themselves can be positively excluded. 

The paralyses of the muscles are often temporary, but apt to re- 
lapse. They may occur very early during apparently perfect health, 
or they appear during the course of the disease. Apart from the 
pupils, the abducens and accommodation are affected most frequently. 
According to Moeli accommodation is paralyzed in about 1^ per 
cent of all cases. 

Simple or combined paralyses of the ocular muscles maj- be the very 
first symptom. Boediker {Arch. /. Psych, u. New., XXIII, 2, p. 
313) saw a case which began with bilateral abducens paresis. One 
year later reflex rigidity of the pupil appeared, and four and a half 
years later atrophy of the optic nerve developed. It was only at this 
period that the knee-jerk on the right side was diminished and there 
was slight difficulty in speech. Death occurred eight years after the 
onset of the disease. The muscular disorder was due, in this case, 
to an interstitial neuritic process in the muscle nuclei and nerves. 
Siemerling reports a case which began with unilateral mydriasis and 
paralysis of accommodation. 

A characteristic feature is the so-called reflex rigidity of the pupil 
(vide p. 113), which is present in about half the cases of paresis and 
is rarely observed in other diseases, with the exception of tabes. At 
first the pupil reacts very little and later not at all to the entrance of 
light (Argyll-Robertson symptom) ; still later it does not react to con- 
vergence and accommodation. The pupils may be of normal size, 
contracted or dilated, but narrowing (myosis) is observed most fre- 
quently. The pupils are often unequal, especially at the beginning. 
They usually dilate after the introduction of cocaine (contraction of 
the vessels). When this condition is not full}' developed, the pupil 
may contract unequally, so that it changes its shape on the introduc- 
tion of light, or constantly exhibits an irregular shape. According 
to Salgo (Wien. med. Woch., 1887, 45, 46), irregular shape and 
reaction of the pupil are more frequent than inequality and rigidity 
of the pupil. 

Despite the reflex rigidity of the pupil, it may continue to dilate 



168 THE EYE IN RELATION TO DISEASE. 

for a long time after cutaneous irritation. Later, this reaction grows 
slower and is finally lost. It may also be abolished from the start. 

In 64 per cent of the cases Siemerling found absence of the reaction 
of the pupil to light, usually on both sides ; Uhthoff and Moeli found 
it absent in about half the cases. Moeli found reflex rigidity of the 
pupil in 47 per cent (among 500 cases), doubtful reaction in 4 per 
cent and sluggish reaction in 10 per cent. 

Uhthoff {Berl. Uin. Woch., 1886, No. 3) found reflex rigidity of 
the pupils 492 times among 4,000 insane; of these 421 (85.5 per cent) 
were paralytic dements. Thomsen {Charite-Annal., XI) found 172 
cases of general paresis (83 per cent) among 205 patients who exhibited 
reflex pupillary rigidity. Moeli (Centralhl. f. Aug., 1885, Sept.) 
found this symptom in only 1.6 per cent of non-paretic insane. 
Moeli {Arch. f. Psych, u. New., XIII, p. 621) also made a special 
examination of the reaction of the pupil to cutaneous irritants. 
When the reaction to light was good in general paresis, the reaction 
to cutaneous irritants was almost always present. When the former 
was impaired the reaction to cutaneous irritants was often absent, 
and was absent as a rule when the former was abolished. The knee- 
jerk was usually intact when the pupillary reaction to light was good, 
but was only present in about half the cases when the latter was 
abolished. 

Keflex rigidity of the pupil may long be the sole prodromal symp- 
tom of general paresis. But the evil result will not invariably follow. 

Motor disorders of a cortical nature (convulsions, speech disturb- 
ances, etc.) are very common; they rarely afl^ect the eye (ptosis). 
Conjugate deviation of the head and eyes is quite frequent during 
the "attacks." Zacher {Arch. f. Psych, u. Nerv., XIY, p. 463) 
observed this symptom in 12 cases. The head and eyes were usually 
turned (7 cases) toward the side of the predominant irritative 
symptoms; in 2 cases without such symptoms they were turned 
toward the side opposite to the paralysis. In 2 cases the head 
and eyes were turned in opposite directions, evidently dependent on 
the situation of the localities of greatest cortical irritation. 

Bechterew {Jahr. f. Aug., 1881, p. 316) saw conjugate deviation 
of the head and eyes toward the right; right hemiplegia and devia- 



DISEASES OF THE NERVOUS SYSTEM. 169 

tion toward the left subsequently developed. Foerstner {Arch. f. 
Psych, u. New., VIII, 1, p. 182) observed conjugate deviation 
toward the left which lasted two weeks. He also reports unilateral 
disturbance of vision with reacting pupil and normal ophthalmo- 
scopic findings in the eye of that side of the body which was subject 
to the more severe seizures. 

According to Blocq {Arch, de Neurol., 1889, ISTo. 54) ocular 
migraine (scintillating scotoma) is a frequent herald of general paresis. 
Pick {Prag. med. Woch., 1899, No. 1) makes a similar state- 
ment. Graff {Jahr. f. Rec, 186, p. 291) reports a complication with 
facial hemiatrophy and neuro-paralytic keratitis. In another case 
hemorrhages into the conjunctiva suddenly developed ; the secretion 
of tears was checked, the cornea became dry but remained clear. 
The patient died soon afterward from a hemorrhage into the locus 
cseruleus and the smaU descending root of the trigeminus. 

In general paresis, according to Sgrosso {Psychiatrici, Bd. Y), a 
conjunctivitis sui generis occurs, dependent upon nervous stases in 
the palpebral conjunctiva ; it is said to appear particularly in the late 
stages. It is true that conjunctivitis often occurs at this time, but 
its causes are much simpler. 

According to the teachings of pathological anatomj', what is known 
as general paresis is a symptom rather than a definite disease. It is 
a progressive degeneration of the cortex which is most marked in 
the frontal lobes, but may vary in character. Apparently either the 
vessels, nerve fibres or interstitial tissue can be primarily af- 
fected. Moreover, it is often complicated with other focal and 
sj^stematic diseases of the brain and spinal cord, even with multiple 
neuritis, or it occurs as a complication during their course. The 
majority of the eye symptoms are probably due to these frequent com- 
binations, all of which owe their development to a common cause. 
For example, Lawford {Lancet, 1883, II, p. 1090), among 7 cases of 
atrophy of the optic nerve in general paresis, found spinal sclerosis 
in 5 cases, tabes in 1 case and lateral sclerosis in 1 case. While the 
insanity implies disease of the frontal cortex, the visual cortex dis- 
plaj^s no signs of irritation such as hallucinations, etc. The pupillary 
symptoms which are most characteristic indicate focal affections in 



170 THE EYE IN RELATION TO DISEASE. 

the neighborhood of the muscle nuclei. These also vary in character 
and are probably co-ordinate with the main disease. 

In Paralysis Agitans 

(Parkinson's disease) , which is probably due to insufficient cortical in- 
fluence upon the motor organs, Galezowski {Bee. d^Ophth., Feb., 
1891) usually found no eye symptoms except slight tremor of the eye- 
lids (very rarely unilateral) . He sometimes found amblyopia with 
negative ophthalmoscopic appearances and occasionally defects in the 
field of vision. Galezowski {Neurol. Centralbl., 1891, p. 224) also 
reports the sudden loss of the inner, upper and lower quadrants of 
one eye, without ophthalmoscopic findings but with slow reaction 
of the pupils. This was evidently a unilateral peripheral affection 
of the optic nerve, similar to that in Graefe's retrobulbar neuritis. 

Gray atrophy of the optic nerve, bilateral ptosis, fixity of gaze, 
etc. , are also reported occasionally in paralysis agitans. According to 
Galezowski the imperfect movement of the head and eyes interferes 
with close work. According to Debove {Jahr. f. Aug., 1878, p. 252), 
reading was impossible because, after reading one line, the eyes could 
not be carried to the next but were compelled, by a sort of imperative 
movement, to continue along the line already read. 

Nystagmus is very rare in paralysis agitans. Wille {Corresp. f. 
Schweiz. Aerzte, 1888, No. 8) observed it in one case. 

Diffuse Encephalitis, 

according to Graefe's original idea, was said to be the cause of the 
corneal softening of poorly nourished, marantic infants, because 
numerous granulo-f atty corpuscles were found in all parts of the brain 
in such patients. It was soon learned, however, that such findings 
are normal at this age. The affection in question is a simple desic- 
cation keratitis associated with insufficiency or abolition of the lid 
movements. If the causal disease, usually cholera infantum, sub- 
side the corneal affection may recover, after exfoliation of the 
necrotic parts. 

Among three cases of diffuse sclerosis of the brain Erler (Diss. 
Tubingen, 1881) found a case of bilateral abducens paralysis, 



DISEASES OF THE NERVOUS SYSTEM. 171 

although the paralysis was not uniform on the two sides. The 
symptoms of diffuse cerebral sclerosis are essentially those of increased 
intracranial pressure and irritation of the cortex. Sluggish reaction 
of the pupils is present as a rule; nystagmus is very often noticed. 

Schmaus {Neurol. Centixdbl., 1888, p. 626) also observed a left 
abducens paresis in a girl of three years. The pupils were dilated 
and sluggish ; there was considerable impairment of vision and hori- 
zontal nystagmus ; the left facial nerve was slightly paretic. 

Quincke (Deutsch. Arch f. kl. Med., XXYII, p. 193) saw choked 
neuritis in a case of hemorrhagic encephalitis. 

According to Leube, Ziemssen and Merkel {vide Foerster, Z.c, 
p. 125), 

CJieyne- Stokes Breathing, 

which is more or less frequent in numerous diseases of the brain, 
is attended with characteristic pupillary symptoms. During the 
respiratory interval the pupils are narrow and do not react to light. 
Moderate dilatation sets in with the renewal of respiration. When 
hemiplegia was also present the contraction of the pupils was at- 
tended by horizontal associated movements of the eyes, which were 
most marked toward the paralyzed side. According to Murri 
{Jahr. /. Aug., 1888, p. 446), the respiratory intervals may be short- 
ened voluntarily by opening the lids, but according to my experience 
this does not succeed in all cases. I was unable to discover visible 
changes in the fundus during Cheyne-Stokes breathing. The con- 
traction of the pupils during the respiratory intervals depends prob- 
ably upon paresis of the sympathetic. 

Injuries to the Brain 

may produce eye symptoms in various ways: a. By direct de- 
struction or irritation of those parts which produce local symp- 
toms, for example, hemianopsia or cortical blindness in injury to the 
occipital region, or conjugate deviation to the right in injury to the 
left side of the skull, etc. Ball's case {Jahr. f. Aug., 1883, p. 329) 
is very instructive in regard to the occurrence of nystagmus. After 
injury to the parietal bone, left hemi paresis ensued with epileptoid 



172 THE EYE IN RELATION TO DISEASE. 

attacks ; during the latter the eyes were first turned to the right, then 
nystagmus occurred, then deflection to the left (left-sided irritative 
symptoms, then diminution with enfeebled cortical innervation, pass- 
ing later into right-sided irritative symptoms) . Beger {Jahr. f. 
Aug., 1880, p. 432) observed temporary nystagmus after injury in 
the region of the eyebrows. 

b. By indirect injury, as in the frequent fractures at the base from 
contrecoup. All the nerves at the base may be torn or their function 
greatly impaired, giving rise to manifold paralyses (the abducens is 
attacked with comparative frequency) and sensory disturbances. 
ITeuro-paralytic keratitis may develop in anaesthesia of the first 
l)ranch of the trigeminus. 

Special importance attaches to the injuries of the optic nerve 
which are sustained in this manner. Berlin has shown that fissures 
at the base, due to contrecoup, pass through the optic foramen with 
remarkable frequency, and not rarely through both foramina. In 
such cases the injury, which is often apparently trivial, is followed 
immediately by unilateral or bilateral blindness with abolition of the 
reaction of the pupil to light and, for a time, no ophthalmoscopic 
findings. This may be the sole symptom. For example, I had under 
observation a railway official who, during a trip, struck the rim of 
the orbit lightly against some obstruction. The patient was not 
unconscious for a moment, but from that time on he was blind upon 
the side of the injury. 

Berlin has shown that in fissures through the optic foramen the 
nerve is also torn. But a hemorrhage into the optic nerve or its 
sheath, as the result of the concussion, is also sufficient to produce 
blindness. 

In accordance with the peripheral character of the injury atrophy 
of the optic papilla always develops. According to Berlin, ophthal° 
moscopic examination in daylight shows beginning atrophy at the 
end of two weeks (the color is a pure yellow). At the end of three 
weeks it is demonstrable with artificial illumination. More or less 
pigmentation of the atrophic nerve subsequently develops in not a 
few cases. Knapp (Arch. f. OpMli., XIY, 1, p. 252) was the first to 
describe two cases of this kind. The blindness and atrophy of the 



DISEASES OF THE NERVOUS SYSTEM. 173 

optic nerve are usually complete. But Capron {Arch, f, Aug., 
XVIII, p. 407) observed, after a fracture at the base, that only the 
inner three- fourths of the nerve was shining white and atrophic; 
quantitative perception of light was still retained. Such cases also 
exhibit a decided tendency to pass into complete atrophy. In 
Rieger's case {Jahr. f. Aug., 1887, p. 299) the capillary hypersemia 
of the nerve, moderate impairment of vision with concentric narrow- 
ing of the field and color disturbance, must be attributed to a fissure 
at the optic foramen with comparatively slight implication of the 
optic nerve. 

It is well known that these basal fissures and fractures may be far 
distant from the point of injury. Thus, Hoog {Jahr. f. Aug., 1887, 
p. 263) saw paresis of the right facial and abducens nerves after a 
blow upon the intersection of the coronal and sagittal sutures. 
Vossius (ilioTi. /. Aug., 1883, p. 284) observed, after a fall upon both 
tubera ischii, blindness of the right side followed by atrophy of the 
optic nerve, which could hardly be explained in any other way 
than by a fissure at the base of the skull. After a fracture of the 
frontal bone, Tuffier {Jahr. f. Aug., 1884, p. 353) observed nasal 
hemianopsia, evidently from implication of the anterior angle of the 
chiasm. 

In indirect fractures of the base the bony w^alls of the orbit may 
be directly involved. Hemorrhages into the orbit, exophthalmus, 
hemorrhages into the eyelids, pressure on and rupture of the optic 
nerve, muscular paralyses, etc., may be produced in this way. 

c. Eye symptoms may result from a hemorrhage which may give 
rise to general symptoms (compression of the brain) and also, accord- 
ing to its situation, to local symptoms. In injuries to the skull, blood 
is often found in the sheaths of the optic nerve, extending forward 
to the sclera. Talko {3Ion. f. Aug., 1873, p. 341) explained a 
hemorrhage into the vitreous as the result of compression of the 
retinal vessels consequent upon an extravasation of blood into the 
intervaginal space, but this explanation is far-fetched. If the blood 
is extravasated between the dura and the bones it cannot enter the 
intervaginal space of the optic nerve. 

Hutchinson {Ophth. Rev., 887, p. 97) states that in compression 



174 THE EYE IN RELATION TO DISEASE. 

from meningeal hemorrhage there is usually mydriasis on the cor- 
responding side, but it may also be bilateral ; myosis is very rare. 
He explains the mydriasis by direct pressure on the motor oculi. 

The symptoms of compression of the brain (unconsciousness, coma, 
slow pulse and respiration, etc.) also include dilatation of the pupils, 
which do not react to light. 

d. If the injury is followed by meningitis, the corresponding 
symptoms are produced. Probably all cases of neuritis or neuro- 
retinitis after injuries are due to secondary meningitis {vide p. 150). 
Cerebral abscesses which are due to trauma, and often do not give 
rise to symptoms until the lapse of years, show no peculiar feature 
{vide p. 131). 

e. A series of symptoms remain which are attributed to cerebral 
concussion and are supposed to be purely functional disorders with- 
out anatomical findings. Macroscopic findings are not infrequently 
absent in cases which were evidently due to material injuries — for 
example, in basilar paralyses of the nerves. In individual cases, 
however, careful microscopical examination occasionally shows 
lesions (capillary hemorrhages, changes in the vessels, especially in 
the small and smallest ones, corkscrew-shaped axis cylinders, i.e., 
torn nerve fibres, etc.) which sufiice to explain the irritative or para- 
lytic symptoms. 

According to Hutchinson (Z.c.) the signs of cerebral concussion 
include a certain sluggishness in the reaction of the pupil, without 
pronounced myosis or mydriasis. Unilateral or bilateral mydriasis 
is rare, and myosis occurs only when inflammatory processes 
develop. 

Nystagmus, a sign of insufficient cortical activity or interference 
with the conduction of the innervation impulse which starts from the 
cortex, is seen not infrequently. 

In addition there may be symptoms which correspond, in the main, 
to those of hysteria : concentric narrowing of the field with and with- 
out disturbance of central vision and the color sense, often associated 
with sensory disturbances on one side of the body. Such a condition 
may be called traumatic hysteria. It is also known as traumatic 
neurosis. It is assumed that the symptoms are central in character 



DISEASES OF THE NERVOUS SYSTEM. 175 

and that they have no anatomical substratum. According to our 
present anatomical knowledge, however, unilateral concentric narrow- 
ing of the field of vision can only be peripheral in character. The 
subject will be further considered in the discussion of hysteria. 

Heatstroke or sunstroke may be regarded as a peculiar form of 
cerebral trauma. According to Spalding {Jali7\ f. Aug., 1887, p. 
519) only one case has been reported in which blindness occurred after 
sunstroke, but there have been six cases of optic neuritis with 
restoration of vision (these are probably Holz's cases mentioned 
below). Kesteren {ibid., 1882, p. 442) reports a case in which yellow 
vision existed for three months after exposure to the intense heat of 
the sun. The ophthalmoscope showed a slight neuritis. Hotz {Jahr. 
f. Aug., 1879, p. 255) describes six cases of unilateral and bilateral 
neuritis, with notable disturbance of vision, which he attributes to 
heatstroke. The cause is said to be an effusion at the base of the 
brain with secondary disease of the optic nerve sheaths. 

Finally, we will consider a few cerebral diseases in which we have 
to deal with more or less sharply defined processes. 

Porencephaly, 

In case of cavities in the brain either congenital or acquired, 
and which are usually the result of large spots of softening, symptoms 
arise from absence of the affected parts. Among them may be visual 
disorders and paralyses. If the cavity is not located centrally as re- 
gards the primary ganglia and muscle nuclei, there will, however, be 
secondary degeneration of the interrupted conducting paths. In the 
optic nerve this is visible as simple gray atrophy. If it is congenital 
or arises in early childhood, such atrophies may be due to arrested 
development of fibres or to the fact that they are not medulla ted. 
Nystagmus may be observed (Otto, Arch. f. Psych, u. Nerv., XYI, 
1, p. 215), and is attributable to imperfect development of the cor- 
tex and its peripheral connections. 

Fuerstner and Stuehlinger (^rc/i. /. Psych, u. Nerv., XVII, p. 1) 
observed the following eye symptoms in porencephaly : 1, unilateral 
reflex rigidity of the pupil and gray atrophy on the same side ; 2, 
bilateral gray atrophy and ptosis of the leftside; 3, bilateral gray 



176 THE EYE IN RELATION TO DISEASE. 

atrophy and rigidity of the pupil ; 4, bilateral gray atrophy of the 
optic nerve. 

The diagnosis of porencephaly during life is hardly possible and 
the findings in the eye furnish no data. The local diagnosis of the 
site of the affection is sometimes possible, and the eye symptoms may 
then prove very useful. 

Bulbar Paralysis and Allied Diseases. 

In the typical forms of bulbar or glosso-pharyngeo -labial paralysis 
eye symptoms are wanting. The disease presents an ascending and 
a descending form, and may be complicated v^ith eye symptoms in 
two ways. In the descending form we find sympathetic nerve 
lesions with oculo-pupillary and vasomotor symptoms, passing from 
irritation into paralysis. In the ascending form there are some- 
times sensory disturbances (trigeminus) and paralytic symptoms 
referable to the external and internal ocular muscles and the ocular 
facial nerve, and occasionally disturbances of vision. In these 
paralyses the nuclei, the roots of the nerves, or even the peripheral 
nerves within the cranium may be primarily diseased. Apart from 
the continuous extension of the principal focus, isolated sclerotic and 
atrophic foci may develop, not alone in the brain but also in the 
peripheral nerves. 

In typical bulbar paralysis such symptoms are extremely rare. 
Ritchie {Glasgow Med. Journ., XII, 1888) saw bilateral gray 
atrophy of the optic nerve, with considerable impairment of vision 
and dilated, immobile pupils. Heller {Petersburg med. Woch., 
1882, No. 9) found right abducens paralysis which recovered. 
Eisenlohr {Zeitschr. f. kl. Med., I, 3, p. 435) observed difference 
of the pupils in one case, paresis of the orbicularis in another case. 
Fischl {Prag. med. Woch., 1879, No. 4) found in acute bulbar 
paralj^sis, paralysis of the left abducens, levator palpebrse superioris, 
and the ocular facial; the paralyses recovered. Kahler {Wien. med. 
Presse) reports in a woman of thirty-seven years paralysis of the 
frontal and orbicularis palpebrarum, while sight and ocular move- 
ments were normal, and he mentions similar cases reported by Bird- 
sail and Remak. Minot {Jahr. /. Aug., 1879, p. 249) reports left- 



DISEASES OF THE NERVOUS SYSTEM. 177 

sided ptosis. Difference in the size of the pupils, nystagmus and 
conjugate deviation are found somewhat more frequently. 

Wernicke was the first to differentiate from ordinary bulbar 
paralysis or inferior polio-encephalitis, a special form known as 
superior polio-encephalitis, in which eye symptoms constitute an 
essential feature. This disease is either acute (hemorrhagic in- 
flammation of the floor of the fourth ventricle, usually in alcoholism) 
or chronic, as in the majority of cases. It maj' run an ascending 
or descending course, may spread in a continuous manner or skip 
certain places. 

On account of the predominant affection of the eye muscles the 
disease is also known as progressive paralysis of the ocular muscles 
or progressive ophthalmoplegia. In Arch. f. Psych, u. New., 
XXII, Supplement, Siemerling has written a detailed monograph 
on the subject. 

The chronic form often shows nuclear disease with degeneration of 
nerve and muscles (fatty and connective-tissue degeneration) ; there 
may also be degeneration of the muscle and nerve, leaving the nucleus 
intact; or sclerotic foci interrupting conduction in the nerve, while 
the remainder of the nerve, the muscle and nucleus are intact. The 
findings may also be entirely negative (Eisenlohr, Neurol. 
Centralhl., 1887, Nos. 15-17; Bristowe, Brain, VII, p. 313). 

The clinical symptoms consist of progressive paralyses of the 
ocular muscles. They are almost always bilateral. They may be 
complete or incomplete, and affect the internal or external ocular 
muscles, or both. The paralyses are usually irregular; ptosis is 
comparatively rare. They may disappear entirely or in part, and then 
relapse, but on the whole the process advances. All the symptoms 
which may result from disease of the nuclear region, whether 
nuclear, perinuclear, or internuclear {vide p. 71), are observed more 
or less frequently — for example, reflex rigidity of the pupil, paralysis 
of convergence, divergence paralysis (more correctly, spasm of con- 
vergence), and not infrequently nystagmus. In one case Siemerling 
observed protrusion of the right eyeball; Lichtheim noted bilateral 
protrusion, more pronounced on the left side. 

It is only in exceptional cases that progressive ophthalmoplegia 
12 



178 THE EYE IN RELATION TO DISEASE. 

is an independent disease. In some cases the process is a descend- 
ing one, and bulbar symptoms develop to which the patient succumbs, 
or the disease is a part of multiple sclerosis, tabes, and other 
diseases of the spinal cord. It is also a forerunner of insanity, 
particularly of general paresis. 

Acute superior polio-encephalitis is much rarer {vide Salomon- 
sohn, Deutscli. med. Woch., 1891, p. 849). It begins with pro- 
nounced somnolence, although the patient is entirely conscious. 
Then advancing paralysis of the ocular muscles develops, progress- 
ing to more or less complete ophthalmoplegia. Death occurs in 
somnolence within one or two weeks. Salomonsohn's case is the 
only one in which recovery occurred. 

In Wernicke's three cases the ophthalmoscope showed neuritis 
(redness of the papilla, with or without swelling) and in two cases 
retinal hemorrhages. Fever was never observed, and even subnormal 
temperatures occur„ Of Wernicke's three cases two occurred in hard 
drinkers, the third was due to sulphuric-acid poisoning. Thomsen's 
two cases {Arch. f. Psych, u. Nerv.^ XIX, p. 185) and Kojewni- 
koff's case {Prog. Med., 1887, Nos. 36 and 37) were also hard 
drinkers. Salomonsohn's patient, who recovered, did not suffer from 
alcoholism. 

The anatomical lesion is an hemorrhagic encephalitis of the gray 
matter at the floor of the fourth ventricle and the aqueduct of 
Sylvius; numerous punctate and a few larger hemorrhages; the 
small vessels and capillaries are distended, but their walls are normal : 
granular corpuscles are found in the vicinity of the hemorrhages. 

Somnolence serves to distinguish the disease from simple nuclear 
paralysis. If there be no paralysis the symptoms are those of so-called 
nona and the allied somnolence of negroes, which is attended with 
great general emaciation and increasing muscular weakness and 
apathy, without rise of temperature or disorder of sensation and 
motion, and which terminates in death. The benign maladie de 
Gerlier (vertige paralysant), an evidently infectious disease which 
is manifested by vertigo, staggering gait, great muscular weakness 
and double ptosis, also points to a localization of the lesion in the 
region of the muscle nuclei. 



DISEASES OF THE NERVOUS SYSTEM. 179 

Multiple Sclerosis. 

In multiple sclerosis the eye is very often affected and, indeed, it 
may exhibit symptoms which are characteristic of the disease. 

The principal clinical symptoms consist of tremor when fixing an 
object, nystagmus, peculiar slowness of speech and spastic-paretic 
phenomena of the limbs. There may also be headache, vertigo, 
psychical disorders, convulsions, apoplectiform attacks, visual dis- 
turbances, etc. These symptoms grow worse, walking and standing 
become impossible, the tremor becomes general, intelligence is im- 
paired, and speech becomes unintelligible. Finally, there is paresis 
of the abductors of the glottis, incontinence of urine and feces, etc. , 
and death occurs either from increasing bulbar symptoms, in an 
apoplectiform attack, or from an intercurrent disease. Sensibility 
is undisturbed ; the electrical reactions to both currents are normal. 

All these symptoms may appear occasionally without finding 
sclerotic patches at the autopsy. For example, Carter Gray {Jalir. 
f. Aug.., 1889, p. 526) found only oedema of the brain and extensive 
leptomeningitis of the convexity. As a rule, however, gray foci of 
degeneration are distinctly visible, sometimes in almost all parts of 
the central nervous system. Oppenheim {Berl. kl. Woch., 1887, 
No. 41) also found numerous microscopic foci in the pons, medulla 
oblongata, chiasm and optic nerve, but these had not given rise to 
symptoms. 

The most important ocular symptoms are the nystagmus and 
twitchings. We have already seen that this associated disorder is 
to be regarded as insufficient cortical innervation of the nuclei of the 
ocular muscles. In multiple sclerosis the nystagmus or tremor is 
due to an interruption of conduction between the oculomotor cortex 
and the nuclei of the ocular muscles. Voluntary innervation may 
be conveyed by fits and starts, even when the interference with con- 
duction is located in the peripheral motor nerves. Hence arises the 
possibility of unilateral nystagmus, which has actually been observed 
(Gordon Norris, JaJir. f. Aug., 1888, p. 434). As the favorite site 
of the sclerotic patches is the region of the pons, the nuclei of the 
ocular muscles and the medulla, the nystagmus is probably due in 



180 THE EYE IN RELATION TO DISEASE. 

the main to perinuclear foci in the fibres of the corona radiata 
{vide p. 84). 

The frequency of nystagmus in multiple sclerosis is variously 
estimated. Uhthoff found 12 per cent of typical nystagmus (pendu- 
lum movements around the position of rest) and 46 per cent of 
nystagmus-like twitchings (twitching movements of the eyes toward 
the desired position, either during movements in all or only in certain 
directions). True nystagmus is extremely rare in other diseases 
of the brain. Nystagmus-like twitchings also occur in a great many 
other nervous diseases, but in none with such frequency as in mul- 
tiple sclerosis. 

Distinct restriction of the mobility of the eye in one or more 
directions occurs not infrequently, either with or without nystagmus. 
In these disorders we must also assume that the site of the interrup- 
tion of conduction is on the central aspect of the muscle nuclei 
(probably perinuclear), although it is also possible that the cause 
might attack the nuclei or nerve roots. In the two latter cases, 
however, we would be much more apt to expect complete abolition of 
motion in certain directions, especially upward or downward. 

In addition to these disorders of associated movements, which 
Uhthoff observed in 3 per cent of his 100 cases, other paralyses of 
the ocular muscles are not infrequent. They are in great part nuclear 
in character but may also be peripheral. For example, Leube (Arch. 
/. hi. Med., VIII, p. 1) saw both motor oculi nerves converted into 
thick gray bands. In a number of cases sclerotic foci have been 
demonstrated in the peripheral nerves. Uhthoff noted 6 cases of 
abducens paralysis (unilateral in 4 cases), 3 cases of partial motor 
oculi paralysis, 3 cases of paralysis of convergence, and 2 of ophthal- 
moplegia externa, i.e., muscular paralyses in 17 per cent. These were 
distinct paralyses, but a less degree of impairment of mobility is 
much more common. The paralyses almost always recover, but re- 
lapses may occur. In only three cases (abducens paralysis) did they 
appear at the beginning of the disease or as prodromata. 

Changes in the pupils are rare in multiple sclerosis. Uhthoff (Z. c. ) 
found 1 case of reflex rigidity of the pupil, 4 cases of myosis with 
slight reaction to light and convergence, in 1 case the reaction to 



DISEASES OF THE NERVOUS SYSTEM. 181 

light very much diminished but without myosis, 3 cases of unequal 
size of the pupils, 2 cases of slight convergence reaction despite com- 
paratively good reaction to light, i.e., anomalies of the pupils were 
present in 16 per cent of the cases. In the majority there were only 
slight deviations from the normal condition. Parinaud {Prog. Med. , 
Aug. 9th, 1884) also mentions myosis with considerable increase of 
the reaction to light and marked contraction during convergence and 
fixation, i.e., increased reflex excitability of the pupil. Thus, the 
pupils show no characteristic changes in multiple sclerosis, as they 
do in progressive paralysis. 

Much more importance attaches to the disturbance of vision and 
the ophthalmoscopic appearances. The disturbance of vision is 
peripheral, — a central scotoma, occasionally for colors only, irregular 
narrowing of field of vision with or without disturbance of central 
vision, or both combined, or in comparatively rare cases concentric 
narrowing. Both eyes or one alone may be affected. It often 
develops very rapidly, may undergo improvement, and even disap- 
pear entirely. The patient usually has a sensation of a more or less 
dense mist, without subjective light sensations. Impaired sight may 
appear at the beginning of the disease and may even be the sole 
manifestation for a long time. It increases occasionally with the 
exacerbation of other symptoms or with bodily strain, and on the 
whole runs a very changeable course. The central scotoma is rarely 
absolute and complete blindness is rarely observed. Hemianopic 
sj^mptoms are infrequent and occur only in complications with other 
diseases of the brain. 

The visual symptoms point to a partial retrobulbar affection of the 
optic nerve. Characteristic changes are found sometimes imme- 
diately behind the eye : foci of granular degeneration of the medullary 
sheaths, while the axis cylinders remain intact. There is sometimes 
proliferation of the interfibrillary connective tissue which becomes 
finely granular and fibrillated in addition, proliferation of nuclei 
in the larger septa of connective tissue, especially near the 
vessels and in the finest interfibrillary bands (interstitial neuritis). 
Dilatation and proliferation of the small vessels may also be found in 
the intracranial portion of the optic nerve or in the chiasm. 



182 THE EYE IN RELATION TO DISEASE. 

Pathologically the disease of the optic nerve in multiple sclerosis 
stands midway between pronounced neuritis and simple atrophy. 
The process begins in the finer connective-tissue septa, then passes 
to the coarser ones ; the atrophy of the nerve substance is secondary. 
The atrophy and destruction of the medullary sheaths are rapid and 
complete, while the axis cylinders often remain permanently intact. 
According to Uhthoff the vessels are not primarily diseased. 
Whether this is true of the optic nerve affection in all cases which 
belong clinically to multiple sclerosis is very doubtful, to judge from 
the experience in other diseases of the brain and cord. The clinical 
characteristics are the occurrence of focal symptoms and the mainte- 
nance of conduction, although this is interfered with to a greater or 
less extent. 

As the majority of nerve fibres within the foci of disease remain 
intact, ascending or descending degeneration of the optic nerve does 
not develop at all or is very slight. Nor does the retina show any 
atrophic changes. In one case Uhthoff observed a wedge-shaped 
atrophy of the retina with pigmentation as the result of obliteration 
of an arterial twig. 

This corresponds with the ophthalmoscopic findings. Pronounced 
atrophy of the optic nerve is rare (3 per cent) , incomplete and partial 
atrophy is much more common (19 per cent). The ophthalmoscopic 
appearances are often (18 per cent) very similar to those of toxic 
amblyopia (nasal half of the nerve grayish-red, cloudy and often 
obliterated, temporal half pale " like dull porcelain"); in 6 percent 
Uhthoff found neuritis, and this, as a matter of course, may termi- 
nate in white atrophy (five cases in literature). Only 4 per cent 
showed normal ophthalmoscopic findings. 

Very often there is a striking disproportion between the appear- 
ance of the optic nerve and the disturbance of vision, the latter being 
much more marked than the ophthalmoscopic appearances would lead 
us to expect. It may even be considerable when the ophthalmo- 
scopic appearances are normal. This corresponds entirely to the 
anatomical fact that the axis cylinders in the patches of sclerosis are 
intact in great part, but probably conduct poorly on account of 
insufficient isolation. 



DISEASES OF THE NERVOUS SYSTEM. 183 

In the course of the visual tracts the degenerative foci are found 
most frequently in the optic nerve, rarely in the chiasm and 
tractus. They also occur in the primary optic ganglia (Schuele, Arch, 
f. kl. Med., VII, p. 259). 

The patches which are situated in the visual tracts correspond 
entirely to those in other parts of the brain. Marie and Rindfleisch 
assume a primary disease of the vessels, Charcot (and Uhthoff) a pri- 
mary disease of the neuroglia, Adamkiewicz a primary affection of 
the nerve fibres. In fact, all three anatomical processes really occur. 
When they develop in multiple patches and the axis cylinders 
remain intact for a long time so that conduction is not completely 
interrupted, the clinical picture of multiple sclerosis is produced. 
We will again refer to analogous conditions in other diseases of the 
brain and cord. 

2. Diseases of the Spinal Cord. 

Diseases of the spinal cord per se give rise to eye symptoms only 
when the region of the cilio-spinal centre is affected directly or indi- 
rectly. Other eye symptoms occur only when the disease of the cord 
extends to the cranial cavity or in case of complications. Both are 
very frequent. 

Tabes Dorsalis. 

The eye symptoms arc very important in tabes dorsalis. They 
may decide the diagnosis and not infrequently constitute the first 
symptom of the impending disease. This is true particularly of gray 
atrophy of the optic nerve and of the muscular disorders, but vaso- 
motor and secretory anomalies are not uncommon. 

Tabes is often associated with general paresis, insanity, bulbar 
paralysis, multiple sclerosis, or with other systemic diseases of the 
cord. 

Atrophy of the optic nerve in ataxia appears ophthalmoscopically 
as a gray discoloration of the papilla, which is first visible on the 
outer half, then extends slowly over the inner half of the nerve until 
the papilla has a uniform gray color and is slightly excavated. The 
details on the surface of the papilla, especially the tendinous network 



184 THE- EYE IN RELATION TO DISEASE. 

of the lamina cribrosa, remain clearly visible as in glaucomatous 
atrophy, and in contrast with post-neuritic white atrophy in which 
the meshes of the lamina cribrosa are invisible or very indistinct. 
When there is pronounced physiological excavation, it is quite possi- 
ble to mistake it for glaucomatous excavation, particularly in the last 
stages. This is especially true when the gray atrophy occurs in short- 
sighted eyes, and the myopic meniscus (crescent) , together with the 
atrophy of the choroid which has been drawn over on the inner side of 
the optic nerve, simulates the appearance of the glaucomatous " halo." 

Inflammatory phenomena are entirely absent in gray atrophy. 
As a rule, the calibre and degree of fulness of the retinal vessels are 
also unchanged, because the original process is located behind the 
entrance of the central vessels. The retinal hemorrhage in gray 
atrophy reported by Auscher (Jahr. f. Aug., 1887, p. 528) must be 
regarded as an accidental finding. 

The absence of inflammatory phenomena is also anatomically 
characteristic of gray atrophy. The affection is a primary atrophy 
of the nervous elements of the trunk of the nerve, perhaps following 
granular degeneration. 

At a later period atrophy also occurs in the finer connective-tissue 
bands within the larger meshes. The coarser septa retract and 
become more homogeneous and sclerosed. The walls of the small 
vessels within them also become sclerotic. On the whole the structure 
of the optic nerve with its regular alternation of nerve substance 
and septa is retained. Signs of interstitial processes and nuclear 
proliferation are never present, and the subsequent thinning of the 
nerve is never so great as when there have been preceding interstitial 
inflammatory changes (retrobulbar neuritis) . The entire process thus 
appears to be a simple descending atrophy. The retina constantly 
exhibits atrophy of the nerve-fibre and ganglion-cell layers; the other 
layers appear essentially normal. In only one case did Uhthoff , from 
whom we copy this description, observe rarefaction of the outer part 
of the external granular layer. 

The atrophic nerve fibres, which are often varicose at the be- 
ginning, usually remain intact with the medullary sheath ; in very 
rare cases the latter also degenerates. 



DISEASES OF THE NERVOUS SYSTEM. 185 

The disturbance of vision consists of diminution of central vis- 
ion, concentric narrowing of the field and disorder of the color 
sense. Central vision usually possesses a definite relation to the 
narrowing of the visual field, and is so much more impaired the 
more the boundaries of the field approach the point of fixation. 
The impairment is usually very slow, and years elapse (even ten 
to twenty) before complete blindness. Temporary improvement 
may occur, especially at the beginning, but on the whole the 
process is progressive. An arrest, either temporary or permanent, 
may occur, however, at any period, but this is not common. Cases 
in which sight is lost within a year are included among the rapid 
ones. Hirschberg's case ("Klin. Beobacht.," 1874), in which 
vision was almost entirely lost in eight weeks, is extremely rare. 

It will often be found that in feeble illumination or in artificial 
light, vision becomes disproportionately poorer, although no 
anomaly of the light sense can be discovered. The disorder of the 
field consists essentially of concentric narrowing, often with enter- 
ing angles which slowly enlarge and approach the point of fixa- 
tion. The latter is not usually preserved until the last; an 
eccentric part of the retina is at the end still sensitive to light. 
On the whole the contraction is concentric to the blind spot, not 
to the point of fixation (Foerster). 

Despite the impairment of central vision the visual field may 
remain normal, and the latter may be very much narrowed 
although central vision is good. 

A central scotoma hardly ever occurs and always rouses the 
suspicion of a complication or a false diagnosis. Gowers (Jahr. f. 
Aug., 1881, p. 315) reports a case of combined sclerosis of the 
posterior and lateral columns with gray atrophy of the optic nerve, 
and bilateral, oval, central scotoma, especially for red and green. 
This finding is the typical one in so-called pseudo-tabes (multiple 
neuritis). To this category probably belonged the two cases of 
tabes in children of eleven and fourteen years, in whom Bouchut 
{Gaz. des Hop., 1874, p. 297) observed neuritis and hyperaemia of 
the optic nerve. 

The color disturbance is characteristic of interference with con- 



186 THE EYE IN RELATION TO DISEASE. 

duction {vide p. 29). Real exceptions are very rare, apparent 
ones are more frequent, especially in comparatively rapid cases. 
Prognostically the color disorder is important, because those cases 
in which the color boundaries are very much narrower than those 
for white belong to the rapidly progressive cases. But if the color 
boundaries are only narrowed to correspond with the boundaries 
for white, the process is either very slowly progressive or stationary. 
Usually the color boundaries are somewhat more narrowed than 
those for white, corresponding to the slowly progressive course; 
or an entering angle for the color boundaries is the forerunner of 
a similar contraction of the field of vision in general. 

There are all kinds of exceptions to the ordinary course which 
cannot be entered into here. 

There is very often a disproportion, in both directions, between 
the visible atrophy of the nerve and the disturbance of vision. 
As a general thing the atrophic discoloration of the nerve is 
visible with the ophthalmoscope before a disturbance of vision is 
demonstrable. When tho visible atrophy appears to be much 
greater than we might expect from the amount of disturbance of 
vision, the case is usually a slowly progressive or stationary 
one. There are even cases in which the ophthalmoscope shows 
the appearances of total gray atrophy, although there is hardly 
any disturbance of vision. When the latter is disproportionately 
greater than the visible atrophy of the nerve, the case is generally 
a rapidly progressive one. There are numerous exceptions, how- 
ever, to this rule. 

Atrophy of the optic nerve may begin in any stage of tabes, 
and even precede the first symptom for years. Kahler observed 
it seven years, Charoct ten years, Gowers fifteen and twenty years 
prior to any other tabetic symptoms. The older the individual, 
so much slower is its course. It has been claimed that when 
blindness from atrophy of the optic nerve occurs at an early period, 
especially when it runs a rapid course, a slow course of the tabetic 
symptoms proper may be expected (Martin, Arch. /. Aug., 1890, 
p. 122; Benedict, Wie7i. med. Wocli.. Aug. 14th, 1887). The 
latter writer says : " It is a rule, without exceptions, so far as my 



DISEASES OF THE NERVOUS SYSTEM. 187 

experience goes, that motor tabetic symptoms subside, however 
severe they may have been, as soon as atrophy of the optic nerve 
begins. The latter symptom, however, presents a very unfavor- 
able prognosis." I have seen exceptions to both these statements. 
But a very rapid course of the visual disturbance alway^s arouses 
in me the suspicion of a wrong diagnosis, because this is much 
more common in neuritic and sclerotic processes than in primary 
atrophy of the nerve substance. As a general thing, the prognosis 
of those diseases which may be mistaken for tabes is more favor- 
able, and only those cases in which an autopsy is obtained may be 
regarded as conclusive. 

Both optic nerves are usually attacked, but often at different 
times, so that years sometimes elapse between the affection of the 
two nerves. 

The frequency of optic nerve atrophy in tabes is variously 
estimated. For evident reasons the statistics of ophthalmologists 
furnish a higher percentage than those of neurologists. Gowers 
mentions 13.5 per cent (35 per cent in cases attended with 
psychical disturbances, 8 per cent in those unattended with such 
symptoms), Marina 10 per cent, Walton 21 per cent, Leber 26 per 
cent, Berger 33.7 per cent, Dillmann 2 per cent, Uhthoff (Nerve 
Clinic) only 20 per cent. 

According to Galezowski about two-thirds of all optic nerve 
atrophies are tabetic; Peltesohn found a still higher percentage, 
viz., 78 out of 98 cases. According to other writers the propor- 
tion is lower, and it is evident there are great differences in the 
clinical material of different observers. At all events every gen- 
uine gray atrophy of the optic nerve raises the suspicion of tabes, 
although a long time (ten to thirty years) may elapse before the 
appearance of further symptoms. 

The treatment is not very promising; the best plan is the 
hypodermic injection of strychnia into the temples (0.001 to 0.004 
at a dose). In some cases the improvement is merely subjective, 
for example, in clear weather, etc. To this category belongs the 
apparent improvement from the internal use of santonin; the 
3^eUow vision simulates clearer vision. Caution must be exercised 



188 THE EYE IN RELATION TO DISEASE. 

in the application of electricity to the optic nerve. I have seen 
this followed in several instances by an acute exacerbation. 
Careful cold-water treatment often has a favorable effect on the 
optic nerve trouble as well as upon the tabetic symptoms proper. 
According to Abadie and Desnos suspension has effected an im- 
provement of vision, while Eulenburg, Mendel, Galezowski, and 
Clarke detected no influence. 

There is often a certain independence in the course of the opti- 
cal symptoms as compared with the spinal symptoms, and this may 
also be noticeable in the therapeutic results. For example, Kahler 
{Prag. med. Woch., 1878, No. 36) found that all the ataxic symptoms 
retired under the administration of nitrate of silver, while the visual 
disorder remained unaffected. 

We must enter a caution against vigorous antisyphilitic treat- 
ment despite the well-known relations of tabes to syphilis. [At the 
pressent time great stress is laid upon the value of hydropathic 
and hygienic treatment of tabes as conducted in the best modern 
establishments — not excluding iodide of potassium. — Ed. J 

Foerster emphasizes the carelessness and even cheerfulness with 
which patients endure their affliction. Among my patients with be- 
ginning atrophy of the optic nerve at the onset of tabes, two com- 
mitted suicide in one summer. One case was interesting from the 
fact that under the influence of strychnine injections vision remained 
tolerably fair for a long time. The patient lost patience, however, 
and contrary to my advice electricity was applied by another physi- 
cian. The consequent rapid impairment of sight led the patient to 
commit suicide. 

It is evident from the statements already made that the process in 
the optic nerve begins as a disseminated one, and that the atrophy 
extends in an ascending and descending direction. The middle 
fibres of the nerve remain longest intact, and we may therefore 
infer an action starting from the periphery. This may take place 
most readily at the place where the nerve passes through the un- 
yielding optic foramen. The gray atrophy is also noticeable in the 
chiasm, tractus, and as far as the primary optic ganglia, but there 
is no direct connection with the degeneration in the spinal cord. 



DISEASES OF THE NERVOUS SYSTEM. 189 

Other visual disorders such as homonymous hemianopsia, 
symmetrical defects of the field (according to Berger, these occur 
frequently), central scotomata, etc., are exceptional, but may occur 
in pure dorsal tabes, usually as complications of the later stages. 
The homonymous defects are probably due to foci of degeneration 
in the tract us or the primary ganglia. 

Muscular disorders of all kinds occur with equal frequency in 
tabes. Berger {Arch. f. Aug., 1888) found them in 38 per cent of 
the cases, Dillmann in 41 per cent, Uhthoff in only 20 per cent. 

The muscular paralyses preceding and during tabes are always 
peripheral or nuclear; at the most they are perinuclear or inter- 
nuclear. The nuclei and nerve roots have been repeatedly found 
intact on post-mortem examination. On the other hand, true con- 
jugate or associated paralysis is never observed, except in compli- 
cations. In the case of muscular paralysis, as in tabes itself, the lesion 
is chiefly a primary atrophy of the nervous elements of the nerv3 
fibres and ganglion cells. Pronounced inflammatory or hemor- 
rhagic inflammatory phenomena, for example, inflammation of the 
ependyma of the fourth ventricle and hemorrhages into the subjacent 
gray matter (Buzzard), do not belong to tabes proper, but to multiple 
neuritis, the symptoms of which are well known to be very similar 
to those of tabes. However, the possibility of the combination 
of these two processes is not excluded. 

The paralyses of the external ocular muscles are often bilateral 
but not symmetrical, often unilateral, and frequently affect only 
single muscles. Mydriasis, ptosis and other partial, as well as 
complete, motor-oculi paralyses, and abducens paralysis are the most 
frequent. As a rule thej^ develop suddenly and usually disappear 
after a longer or shorter period either with or without treatment. 
Relapses are frequent. Their duration varies from a few hours 
to a year or more. According to Hutchinson spontaneous recovery 
of a ptosis awakens suspicion of tabes. 

According to Fournier (Bull, de Med., 1887), syphilitic par- 
alysis of the motor oculi involves a larger number of muscles; 
headache, vertigo, epileptiform attacks, aphasia, mental disorders, 
etc., are present at the same time. In the tabetic form, in which 



190 THE EYE IN RELATION TO DISEASE. - ' 

the nerve roots are chiefly involved, a single muscle is affected in 
many cases. In syphilis accommodation suffers at an early period, 
in tabes it remains intact for a long time. Tabetic paralyses are 
often temporary, sometimes lasting only a few hours, and often 
relapse. Syphilitic paralyses are more permanent and develop 
gradually. True as these statements are in general, there are also 
frequent exceptions. 

Rarer symptoms are complicated ophthalmoplegias, such as 
unilateral and bilateral ophthalmoplegia externa and interna 
(Danillo, Central. /. Aug.^ 1891, p. 128; Dillmann, Z.c. ; Hoffmann, 
Arch. f. Psych, u. Nerv.^ XIX, 2, p. 438), or bilateral ptosis 
(Dejerine, Prog. Med., 1884, Xo. 43). In the latter case the muscle 
and nerve were completely degenerated. 

The muscular paralysis sometimes assumes the character of pro- 
gressive ophthalmoplegia (Galezowski). Pel (Berl. kl. Woch., 1890, 
No. 1) observed seven relapses of motor-oculi paralysis precede the 
development of ataxia in an epileptic patient with a neuropathic 
heredity. 

Paralysis of accommodation is frequent, occasionally even at the 
beginning of tabes. Asthenopia from paresis of accommodation 
is also often observed (Landolt, Neurol. Centr., 1891, p. 307). 

According to Galezowski unilateral paralysis of accommodation 
without mydriasis is often the first sign of beginning tabes, and 
is associated in a characteristic manner with anaesthesia of patches 
of the skin in the temporal region. 

Xystagmus is rare ; it is probably perinuclear in origin. Vierordt 
{Berl. kl. Woch., 1886, 21) observed bilateral horizontal nystagmus. 
Berger saw true nystagmus in only one case, but often observed 
slight tremor of the eyes. Dillmann had one case of nystagmus and 
several of n5^stagmus-like twitchings. 

These rarer forms are perhaps always due to complications 
(multiple sclerosis, general paresis, etc.) which are very often 
observed. 

According to Moeli {Char it e- Ann., 1881) the "head symptoms," 
i.e., gray atrophy and paralyses of the ocular muscles, are much more 
frequent when psychical disturbances are present (gray atrophy with 



DISEASES OF THE NERVOUS SYSTEM. 191 

such symptoms, 35 per cent, without them 8 per cent; muscular 
paralyses with psychical symptoms 47 per cent, without them 15 per 
cent). According to Berger {Deutsch. med. Woch., 1885, Nos. 1 
and 2) muscular paralyses are more frequent in tabetics who have 
syphilitic antecedents. The spinal symptoms predominate in other 
cases. 

Pronounced paralysis of the orbicularis palpebrarum is rare, 
but paresis is frequent, and is manifested by tremor on closing the 
lids. 

Berger found 6 cases of facial paralysis in 109 cases, but in only 
one was the ocular facial also affected. 

The following figures give an approximate idea of the frequency 
of the individual muscular affections. Among 100 cases of tabes 
Dilhnann found the motor oculi affected 26 times (9 cases of paresis 
of all branches, 3 cases of paresis of the external branches, 6 of 
ophthalmoplegia interna, i of accommodation alone, 5 of individual 
branches); the abducens 12 times; the trochlearis 3 times. There 
was also one case of nystagmus. The paralyses are more often 
complete and permanent than in multiple sclerosis. ^ 

According to Kahler the most frequent early symptom is abducens 
paralysis, next ptosis; the trochlearis is affected with least fre- 
quency. Paralyses of the associated movements (especially of 
convergence) occur rarely and usually at a later period. In our 
opinion paralysis of convergence is a nuclear or at least a peri- 
nuclear symptom. De Watteville (Neurol. Centralbl., May 15th, 
1887) also states that paralysis of convergence may appear at the 
very onset. Grainger Stewart (Brain, 1880, II, p. 182) also ob- 
served double vision during convergence. Some of the bilateral 
abducens paralyses which, according to Kahler, are so frequent, may 
perhaps be interpreted as spasm of convergence. 

Early paralyses usually recover, the later ones often persist. In 
my experience, the older the individual, the longer the duration of 
the paralyses which eventually disappear. 

Every paralysis of an ocular mascle which occurs suddenly in 
a healthy person (without injury, apoplexy or other brain symp- 
toms, diabetes mellitus or insipidus, syphilis, albuminuria, etc.) 



192 THE EYE IN RELATION TO DISEASE. 

arouses the suspicion of a beginning tabes, especially if it recovers 
in a comparatively short time or subsequently relapses. 

The pupillary symptoms are also very frequent and possess 
great diagnostic importance. We have already noted that mydriasis 
from oculomotor paralysis, with or without implications of accom- 
modation, is not a very frequent symptom. Much more frequent 
are the sympathetic symptoms which indicate irritation or par- 
alysis of the cilio-spinal centre, especially myosis, which may be 
extreme. The reaction to light may be retained or absent, but it 
is always very much diminished. The myosis may be associated 
with ptosis sympathetica. But the latter is often absent and, on 
the other hand, may be present without myosis. 

Dillmann found failure of reaction of the pupil to light (Argyll- 
Robertson symptom) in 76 per cent of the cases ; in 74 per cent the 
knee-jerk was also absent. Myosis was observed in 23.7 per cent 
and inequality of the pupils in 34.2 per cent of the cases. In 
about one-fourth of the cases the rigidity of the pupil to light 
occurred very early, perhaps as the very first symptom. Among 
41 cases with muscular paralysis, rigidity of the pupils to light was 
noted 35 times. The reaction of the pupils to cutaneous irritation 
seems to disappear later than the reaction to light. If the myosis 
is marked, dilatation of the pupils after cutaneous irritation is 
absent. 

In 31.6 per cent of Dillmann's cases the pupils reacted neither 
to light nor to convergence (total reflex rigidity of the pupil, reflex 
deafness) . 

In only 4 cases among 109 did Berger find a normal condition 
of both pupils. In 8 cases the reaction to light took place hy 
means of oscillating movements, which must be regarded as the 
very beginning of the paralysis (Gowers' symptom); in 2 cases 
the reaction to light was absent on one side alone. 

The light reaction of the pupil may be absent where the latter 
is normal in size, in myosis and mydriasis ; in spinal myosis the 
action of mydriatics is diminished, in spinal mydriasis that of 
myotics. Kahler, Mendel and Oppenheim found the oculomotor 
nucleus intact in absence of the light reaction. Hence the lesion 



DISEASES OF THE NERVOUS SYSTEM. 193 

must be sought in the centripetal fibres to the motor oculi nucleus 
or in their origins, unless the condition is due to a toxaemia. 
A peripheral cause is extremely improbable. In Moebius' case 
(Centr. f. New., 1888, l^o. 23), in which there was unilateral light 
rigidity of the pupil, the latter did not exhibit consensual reaction 
{vide p. 115) although the other eye did. In addition to the in- 
terference with conduction in the centripetal optic fibres to the 
nucleus of the sphincter pupillse, we might also assume, in this 
case, an interruption in the connections between the two sphinc- 
ter nuclei, although this explanation is not absolutely necessary 
{vide p. 115). 

The absence of the pupillary reaction to light, which is fol- 
lowed by loss of the reaction to accommodation and convergence 
and to cutaneous irritants, is one of the most characteristic signs 
of impending or beginning tabes and forms an integral part of the 
further clinical history of the disease. It is true that this symp- 
tom also occurs very often in other diseases of the nervous system, 
for example, in general paresis. In this affection, however, the 
mental disturbance or the characteristic disorder of speech will aid 
the correct diagnosis. Moreover, a combination of these two dis- 
eases is observed not infrequently and has also been demonstrated 
anatomically. 

Inequality and irregular shape of the pupils, with or without 
reflex, are found very often, occasionally even the so-called paradox 
reaction of the pupils (p. 116). 

All the pupillary symptoms of tabes cannot be explained by a 
lesion of a single part. In addition to spinal spastic mydriasis and 
paralytic myosis, which point to the cilio-spinal centre, there are also 
nuclear and perinuclear processes (reflex rigidity of the pupil, etc.) as 
a result of which the centripetal fibres of the first reflex arc {vide p. 
116) are interfered with or divided. The nucleus itself may be 
involved at a later period. This explains the comparative inde- 
pendence of the spinal and cerebral pupillary disturbances which 
may be absent or present in various combinations, as the result 
of irritation of one part and paralysis of another. This does not 

imply that occasionally the process may not first attack the 
13 



194 THE EYE IN RELATION TO DISEASE. 

sphincter nucleus itself or its emerging roots. The latter seems to 
be the rule in the other disorders of the ocular muscles. 

In contrast with the rapid onset and disappearance of the cere- 
bral paralyses, the spinal symptoms develop gradually and remain 
permanent. In Klinkert's case {Jahr. f. Aug,, 1885, p. 312) a re- 
flex rigidity of the pupil disappeared after antisyphilitic treatment. 
Eumpf (Berl. kl. Woch., 1838, No. 4) relieved this symptom, asso- 
ciated with myosis, by the aid of the faradic brush. 

Epiphora is a very frequent sympathetic symptom. Berger 
claims to have seen it in half his cases. It is generally a direct 
disorder of secretion, but it may also be the result of imperfect 
action of the orbicularis palpebrarum (Berger). In one case I ob- 
served obstinate epiphora without objective findings as the initial 
symptom of tabes. True " crises lacrymales" sometimes develop. 

Joffroy {U7i. Med., 1888, No. 156) observed slight exophthal- 
mus. According to Berger diminished tension of the globe is 
present in a full third of the cases, but this appears to me to be an 
exaggerated statement. 

Sensory disturbances, such as insensibility of the cornea with 
or without anaesthesia of other parts of the skin supplied by the 
trigeminus, are rare (Westphal, Arch. f. Psych, u. New., VIII and 
IX) . These are not pure cases of tabes but combined diseases of the 
columns of the spinal cord. Neuralgia of the trigeminus, shooting 
pains and abnormal sensations in the eyes, years before the first 
prodromal symptoms, have also been reported, but it is doubtful 
whether they are directly connected with the tabetic process. 

Insensibility of patches of skin near the eye and in the temporal 
region was noted by Galezowski {Rec. d^Ophth., 1888, p. 85) at 
the beginning of tabes. In one of my cases atrophy of the optic 
nerve was preceded by subjective coldness of the eye, first upon 
one side, then upon the other ; further symptoms of tabes have not 
yet developed in this case. 

It is characteristic of the ataxia in tabes that the tottering of 
the patient increases upon closure of the eyes. The imperfect in- 
nervation of the motor organs on account of defective conduction 
of peripheral sensory stimuli may be replaced entirely or in part 



DISEASES OF THE NERVOUS SYSTEM. 195 

by voluntary impulses under the control of the sense of sight. But 
if the cause of the ataxic symptom is central (medulla oblongata 
or cerebellum), or is situated on the motor side of the first reflex 
arc, it will not be affected by voluntary motor impulses. The 
ataxia will not increase on closing the eyes. This is also true of 
hereditary ataxia (Friedreich's disease) in which other symptoms 
(nystagmus) also indicate imperfect conduction of the motor im- 
pulses. 

As is well known, all the symptoms of tabes may occur not 
only in primary, non-inflammatory degeneration of the posterior 
columns of the cord, but also in other chronic systemic and even 
focal diseases of the same locality. Cerebellar diseases, hemor- 
rhages into the pons (Mendel, Berl. kl. Woch., Oct. 10th, 1887), 
etc., may produce similar symptoms. But it is particularly chronic 
multiple neuritis of the posterior spinal roots which produces exactly 
similar symptoms. In such cases the ejQ symptoms often decide 
the diagnosis. Moreover, anatomical findings are sometimes en- 
tirely negative in an apparent tabes dorsalis. 

Hereditary ataxia begins generally at the period of puberty, 
often appears in several members of the same family, and is re- 
garded by Friedreich and the majority of other writers as a 
developmental disorder of the spinal cord. Its principal symptoms 
are : a, disorders of movement, like those of ataxia, in the hands 
and feet; &, ataxic disorders of speech; c, deformity of the feet, 
viz., equino-varus and permanent extension of the great toes; d, 
absence, rarely increase, of the patellar reflex; e, absence of dis- 
orders of sensation, of the visceral reflexes, of the movements of 
the pupil, of cerebral disturbances and spastic symptoms. A 
characteristic ocular symptom is nystagmus or rather nystagmus- 
like twitchings which are almost always present. According to 
Charcot their significance is decisive in the differential diagnosis 
from the tabes of young people. These twitchings (I would pre- 
fer to call them motor nystagmus) are irregular movements of 
the eyes when an object is fixed or followed with the eyes. 
Choreic movements of the head may develop at the same time. 
Mendel {Berl kl Woch., Nov. 24th, 1890, cases 1 and 3) could 



196 THE EYE IN RELATION TO DISEASE. 

produce the symptom by revolving the patient three or four times 
on his axis, although it was absent during rest; this does not 
always succeed (Case 2). 

Other eye symptoms are rare. Joffroy {Gaz. Hebd., 1888, No. 
10) observed slight ptosis and temporary diplopia, and a similar 
case is reported by Ormerod {Brit. Med. Journ.^ 1885, I, p. 435). 
Bernabei {Riform med., May, 1888) observed optic neuritis; 
Wharton Sinkler {Med. News, July 4th, 1885), beginning 
atrophy of the optic nerve and color disturbance ; Mendel {Berl. kl. 
Woch., Oct. 10th, 1887), bilateral paresis of the abducens in a pa- 
tient aged four and a half years. 

Titubation is not increased in this disease by closing the eyes. 

From these statements it is evident that we have to deal with 
a motor ataxia, i. e. , the motor involuntary and voluntary innervation 
is enfeebled, while the centripetal sensory condition is disturbed very 
slightly or not at all. The nystagmus (probably also the speech 
affection) of multiple sclerosis develops in a similar manner. 
Hence voluntary motor innervation cannot aid the involuntary 
innervation, as it does in ordinary tabes. In the latter the voluntary 
innervation under the control of sight partly supplies the imperfect 
involuntary and voluntary innervation after sensory impressions 
and muscular sense ; if the former is removed by closing the eyes, 
the ataxia will be increased. In Friedreich's disease the centripetal 
tracts are, in the main, unimpaired, but the centrifugal tracts are 
not sufficiently innervated, probably on account of insufficient 
development of central fibres. The muscle nuclei (anterior horns 
of the cord) and peripheral nerves exhibit no qualitative anatomical 
changes. Paralyses of the ocular muscles are rare in the different 
forms of progressive muscular paratyses apart from the oculo-pupil- 
lary symptoms in affections of the upper dorsal and lower cervical 
cord. Occasionally the abducens or motor oculi nerve is attacked. 
For example, Zacher {Neur. Centralbl, 1886, No. 23) observed 
inequality of the pupils and right convergent strabismus (probably 
cured abducens paralysis) in amyotrophic lateral sclerosis. The 
bulbar and cerebral nerves were also attacked finally in a case of 
anterior chronic poliomyelitis (Nonne, ibid., 1891, p. 439). 



DISEASES OF THE NERVOUS SYSTEM. 197 

According to Erb {Deutsch. Zeitschr. f. New., Bd. I), the pro- 
gressive muscular dystrophies in their different forms (juvenile 
pseudo-hypertrophic, infantile and hereditary) are to be regarded 
as a clinical unit}', and differ only in regard to the earlier or 
later beginning of the disease and the more marked implications 
of the upper or lower part of the body. Early implication of the 
face is characteristic of Duchenne's infantile form (Landouzy- 
Dejerine type). The mimetic muscles (ocular facial) are almost al- 
ways affected, very rarely the ocular muscles proper. Oppenheim 
{Charite-Annal. , XIII, p. 38) has observed nystagmus in ^ case of 
juvenile muscular dystrophy. 

Moebius' "infantile disappearance of the eye muscle nuclei" 
{Muencli. med. Woch., 1891, ISTos. 3 and 4) may be regarded as a 
peculiar form of atrophy which has become stationary. According 
to Moebius, frequent implication of the facial and constant escape 
of the internal ocular muscles are characteristic features. 

In acute ascending (Landry's) paralysis — which is only in part an 
acute myelitis and may be due to multiple neuritis, and even furnish 
negative anatomical findings — Schwarz {Zeitschr. f. kl. Med. , XIV, 
p. 293) observed secondary contraction in abducens paralysis (he 
calls it convergent strabismus), and Hoffmann {Arch. f. Psych, u. 
Nerv., XV, 1) noted slight ptosis. Hun and Pellegrino also re- 
ported diplopia in one case. 

Achard and Gunion {Jahr. f. Aug., 1889, p. 546) observed blind- 
ness within six days, sixteen days later ascending paralysis (acute 
diffuse myelitis), and death in five months. Three large sclerotic 
foci were found; first, in the optic nerve and tract; second, in the 
cervical cord ; and third, in the dorsal cord, in addition to numerous 
secondary degenerations. 

In acute myelitis Knapp {Jahr. f. Aug., 1885, p. 273) observed 
bilateral ophthalmoplegia and choked neuritis; Dreschfeld {Lancet, 
Jan. 7th, 1882), double neuritis in two cases; Xoyes {Arch. f. Aug., 
X, 3, p. 331), also double neuritis with varying vision; Chauvel {Prog. 
Med., 1880, l^o. 32), optic neuritis with considerable hypersemia, first 
on the right side, then on the left. 

In transverse myelitis Rumpf {Deutsch. med. Woch., 1881, Xo. 



198 THE EYE IN RELATION TO DISEASE. 

32) found diminished vision and a condition "midway between 
neuritis and choked disc;" the faradic brush was attended with sur- 
prising therapeutic effects. Steffan (Ber. d. Heidelberg ophth. Ges., 
1879, p. 90) observed temporary amaurosis, first on the left side, then 
on the right, with slight descending neuritis followed by permanent 
hemianopsia, as forerunners of an acute transverse myelitis. 

Eye symptoms have often been reported in caries of the spine and 
its sequelae. Among 38 cases in children, Bull {Jahr. f. Aug., 1875, 
p. 343) saw 40 cases of neuritis, 32 of very noticeable hypersemia of 
the fundus, and 2 of marked ansemia of the papilla (the children 
likewise were probably anaemic). In 36 cases the pupils were large 
and very sluggish, indicating spinal irritation (spastic spinal mydri- 
asis). Really positive ophthalmoscopic findings do not appear to be 
frequent. Abadie {Ann. d^Ocul., 1876, p. 85) observed double optic 
atrophy in a case of Pott's disease, probably an accidental complica- 
tion. 

The eye symptoms which are often seen in syphilitic affections of 
the cord are probably complications due to a similar affection within 
the cranium. 

In tumors of the spinal cord choked disc is found in the same form 
as in brain tumors but in a smaller percentage of cases. Hirt {Berl. 
kl. Woch., 1887, No. 3) found rigidity of the pupils, ataxia, left-sided 
ptosis and abducens paralysis in an individual who had fifteen to 
twenty cysticerci in the upper part of the cord, beneath the pia 
mater. 

In the spinal affections which are attended with paralysis, the 
same thing happens as in diseases of the nuclear region of the ocular 
muscles. Primary disease of the nucleus, nerve roots and basal 
cerebral nerves produces the same symptoms as the paralysis attend- 
ing degeneration of the nerve, nucleus and muscle (poliomyelitis 
superior). It is only after considering all the other circumstances, 
especially the anatomical relations of adjacent parts, that a definite 
diagnosis can be made of disease of the nucleus or nerve roots, or of 
multiple neuritis, and even then the diagnosis may be unexpectedly 
corrected at the autopsy. 

It may also be difficult to decide, in spinal-cord cases, whether we 



DISEASES OP THE NERVOUS SYSTEM. 199 

have to deal with multiple neuritis or with primary disease of the 
motor nerve nuclei (anterior horns). Even the possibility of a pri- 
mary disease of the muscles must be considered. If the motor fibres 
are destroyed above the nuclei (anterior horns) but the cells of the 
latter are intact, the spontaneous voluntary movements will be 
abolished and the involuntary reflexes retained or exaggerated. The 
disorder of movement is unchanged by opening or closing the eyes, 
as the motor impulse from the cortex is no longer conveyed to the 
cells of origin of the motor nerves. 

If the centripetal spinal paths are destroyed or no longer capable 
of conduction while the centrifugal tracts are intact, the voluntary 
movements under the control of the higher senses (sight) may replace 
in part the automatic movements. If this control is lost, the disturb- 
ance of movement becomes much more pronounced. In such cases, 
also, the differential diagnosis between primary disease of the pos- 
terior columns and multiple neuritis of the nerve roots (tabes and 
pseudo- tabes) may be difficult. The ophthalmoscopic findings (gray 
atrophy or axial neuritis of the optic nerve) may prove decisive. 

Injuries of the Spinal Cord. 

Wharton Jones states that affections of the optic nerve are fre- 
quent after injuries to the spinal cord. Among seventeen rapidly fatal 
cases Allbutt (Lancet, 1870, I, p. 76) saw no changes in the fundus; 
among thirteen chronic cases eight showed varying degrees of hyper- 
aemia of the papilla ; this appeared so much earlier, the higher the site 
of injury to the cord. Vision was impaired very little and despite 
the long duration there was much more tendency to recovery than 
to a transition into atrophy. Hence it was due probably to a vaso- 
motor paralysis. Almost every extensive injury to the cord at once 
produces vasomotor paralysis and rise of temperature upon the side 
of the motor paralysis; this may terminate in trophic disturbances. 
Allbutt never found true neuritis, but Firth {Practitioner, May, 
1886) claims to have seen double optic neuritis in an injury to the 
lower cervical and upper dorsal spine, with temporary paresis of the 
right arm. Fowler {Journ. f. Ophth., Jan., 1891) observed the 
gradual development of double optic-nerve atrophy after an injury to 



200 THE EYE IN RELATION TO DISEASE. 

the spine, followed first by paralysis, later by weakness of both legs. 
This was possibly a mere coincidence. 

In concussion of the spine (railway spine) eye symptoms are quite 
frequent. In part, they are unconnected with the cord (retinal hem- 
orrhages, atrophy of the optic nerve, etc.) ; in part they belong to the 
so-called " traumatic neurosis ;" in part they are due to irritable weak- 
ness of the sympathetic system, especially of its vasomotor functions. 
Schmaus {Virch. Arch., 122, 3, p. 487) has found notable anatom- 
ical changes in spinal concussion, such as necrosis of the nervous 
elements with or without destruction of the neuroglia, and later, 
columnar degenerations, softenings, formation of cavities, etc. In ad- 
dition larger and smaller blood-vessels may be torn, so that the term 
concussion is insufficient in many cases. 

Injuries of the lower cervical and upper dorsal cord produce cor- 
responding oculo-pupillary and vasomotor symptoms of irritation or 
paralysis. The latter are more frequent and may develop from pre- 
ceding irritative symptoms. These phenomena may be important in 
making an accurate local diagnosis, especially in stab wounds. 

Trophoneuroses. 

The trophoneuroses form a transition between the central and 
peripheral diseases of the nervous system. They are often due to pe- 
ripheral diseases, but may also be central in origin. The latter is un- 
doubtedly true, for example, of syringomyelia (formation of cavities 
in the cord) in which, apart from trophic disorders, spastic muscular 
paralyses, general vasomotor and secretory disturbances and the char- 
acteristic partial disturbances of sensation, there are also sympathetic 
(vasomotor and oculo-pupillary) ocular disorders, such as increased 
or diminished secretion of tears, one-sided sweating (rarely abolition 
of sweating) of the head. The presence or absence of oculo-pupillary 
symptoms may possess a local diagnostic value. Syringomyelia 
sometimes exhibits bulbar symptoms, such as abducens paralysis and 
nystagmus, and in the later stages optic neuritis and impairment of 
vision. Concentric narrowing of the field of vision has also been 
noticed. In seven cases Dejerine and Tuiland {Semaine Med., 1890, 
'No. 30) found considerable narrowing of the visual field, especially for 



DISEASES OF THE NERVOUS SYSTEM. 201 

green (up to 10°) ; the ophthalmoscopic appearances were normal. 
They believed that hysteria could be positively excluded in these 
cases. 

Morvan's disease — symmetrical panarities (paronychia) terminat- 
ing in necrosis — appears to be merely a variety of syringomyelia. 

In the other trophoneuroses the symptoms on the part of the sym- 
pathetic or the sensory nerves may predominate. There may or may 
not be definite anomalies or diseases of certain organs, such as the 
thymus, thyroid and pineal glands, although we are unable to 
offer any explanation of the supposed connection. 

In acromegaly or hypertrophy of the terminal parts of the body 
(Pierre Marie's disease), the eyelids are occasionally affected, in ad- 
dition to the fingers, toes, nose, ears, lips, cheeks, tongue, chin, penis, 
clitoris, uvula, xiphoid process, nipples, etc. The affection occurs in 
various combinations but is almost always symmetrical. It consists 
essentially of a thickening, and to a less extent of elongation, of the 
affected bones and soft parts. This distinguishes it from partial 
giant growth, which is usually not so symmetrical and is generally 
noticeable at an earlier age. Acromegaly does not begin until the age 
of thirty or forty years, after general growth has ceased. Atrophy 
of the thyroid and hypertrophy of the hypophysis cerebri are often 
mentioned ; persistence of the thymus gland is frequent but not con- 
stant. There are often pains and other nervous disturbances in the 
growing parts, in which peripheral neuritis and disease of the vessels 
have been found. 

In this disease Surmont {Centr. f. New. u. Psych., 1891, p. 28) 
observed double choked disc terminating in blindness. Minkowsky 
{Jahr. f. Aug., 1887, p. 305) found slight exophthalmus on both sides 
and considerable disturbance of vision with defects in the field ; the 
ophthalmoscopic appearances were normal. Minkowsky believes 
that these symptoms were due to pressure of the enlarged hypophysis 
on the chiasm. Morax {Ai^cli. de Neurol., XYII, p. 436) saw optic 
neuritis in acromegaly. He also mentions a number of hysterical 
symptoms (concentric narrowing of the field of vision, monocular 
polyopia, micropsia, macropsia, etc.). 

Maisonneuve {Prog. Med., May 16th, 1891, p. 413) observed double 



202 THE EYE IN RELATION TO DISEASE. 

exophthalmus, but the elongated and thickened lids still covered the 
eyes. The eyes were situated nearly in front of the orbit and could 
be easily luxated in front of the lids. In addition the pupils, which 
were of normal size, did not react to light, while the reaction to ac- 
commodation and convergence was intact. The fundus was hyper- 
semic; central vision was slightly impaired, the visual field and 
color sense were normal. 

It is evident that the enlarged hypophysis cerebri may occasionally 
produce all the eye symptoms of a non-infectious brain tumor and 
local symptoms corresponding to its situation, i.e., visual disorders 
which point to an affection of the optic tract and chiasm. This oc- 
cured inBignami'sand Bury's cases [Neurol. Cerdral., 1892, p. 20). 

A condition similar to acromegaly, but more diffuse, less confined 
to projecting parts and unilateral, is found in the very rare affection 
known as hemi-f acial hypertrophy. The eye, orbit and lids may also 
take part in this hypertrophy. Hankel (Berl. kl. Woch., 1884, No. 
34) observed a total staphyloma cornese. But as the lids could not 
be closed this would naturally result from an infectious keratitis 
and have no relation to the general hypertrophy. Ziehl {Virch. 
Arch., 1891, p. 92) found in right-sided facial hypertrophy 
marked myopia and convergent strabismus on the same side. I 
have observed a similar case : extreme myopia and extensive choroidal 
changes in the enlarged eye on the side of the facial hypertrophy. 
Shieck (Berl. kl. Woch., 1833, No. 45) observed hypertrophy of the 
lower lid alone, while the eye was normal. 

Progressive facial hemiatrophy is a much more frequent disease 
than the above. It begins, as a rule, with the symptoms of unilateral 
irritation of the cervical sympathetic, which gradually passes into 
paralysis. Then progressive atrophy develops in all the tissues of one 
side of the face with the exception, perhaps, of the bones. In ad- 
dition to vasomotor and oculo-pupillary paralytic symptoms (ptosis, 
myosis, enophthalmus), we find that the integument of the lids grows 
constantly thinner, finally cicatricial in appearance, and is sometimes 
pigmented; the eyelashes and eyebrows become gray and fall out. 
On account of the cicatricial retraction of the integument of the lids, 
the eye is not sufficiently covered and is exposed to all sorts of in- 



DISEASES OF THE NERVOUS SYSTEM. 20^ 

juries. In other cases- the orbital fat atrophies and the eye sinks deep 
into the orbit (Henschen, Jahr. f. Aug., 1883, p. 319; Kuester, Berl. 
kl. Woch., 1882, No. 10; Virchow, ib., 1880, IS'os. 20 and 36). 

Sometimes, however, oculo-pupillar}^ irritative symptoms are 
found in advanced hemiatrophy. For example, Seeligmueller 
{Deutsch. Arch. f. kl. Med., XX, p. 101) found enlargement of 
the left pupil and the palpebral fissure in left facial hemiatrophy; 
both symptoms were intensified by pressure on the superior cervical 
ganglion. 

Total or partial paralyses of the trigeminus with corresponding 
anaesthesia occur with comparative frequency in facial hemiatrophy. 
They may even lead to neuroparalytic keratitis (Graff, Jahr. f. 
Aug., 1886, p. 263). Graff's case, however, was complicated with pro- 
gressive paresis on a syphilitic basis, and began with conjunctival 
hemorrhages. Peripheral anaesthesia of branches of the trigeminus 
(usually traumatic or due to inflammatory processes in the vicinity) 
may also be the starting-point of the disease (Ruhemann, Centr. f. 
kl. Med., Jan. 5th, 1889). 

The beginning of the hemiatrophy may be attributed not infre- 
quently to traumatism, either with injury to the sympathetic (Moe- 
bius, Berl. kl. Woch., 1884, No. 15; Eperon-Xicati, Arch. d'Ophth., 
1883, pp. 193, 423) or a fall upon the head (Delaware, Jahr. f. Aug., 
1880, p. 276) . The atrophy sometimes occurs in the course of a single 
nerve, for example, the left supra-orbital nerve (Karewski, Be?^. kl. 
Woch., 1883, p. 549) or is confined to one temple, with coincident 
hypertrophy of the upper lid (Estor, Rev. de Med., 1888, p. 200). 

The following symptoms have been occasionally observed: choroi- 
ditis and myopia in a girl aged twelve years (Kalt, Jahr. f. Aug., 
1889, p. 517); ptosis, divergent strabismus, cataract, impaired mobil- 
ity of the eye, contracted pupil as the result of an inflammation of the 
maxilla which was also the cause of the hemiatroph\' (Ruhemann, 
Central, f. kl. Med., 1889, Xo. 1) ; small light patches in the fundus 
of both eyes in a case of left hemiatrophy (Spitzer, Wien. med. Blaett. , 
1885, 1^0. 1). [These patches were probably a congenital anomalj'. 
I have found the same condition accidentally in a patient who con- 
sulted me concerning atropine mydriasis.] Eperon [I.e.) saw, upon 



204 THE EYE IN RELATION TO DISEASE. 

the side of the hemiatrophy, diminished vision and concentric nar- 
rowing of the field, with an atrophic spot in the macular region. 
Kahler (Prag. med. Woch., 1881, No. 6, 7) describes a hemorrhage 
into the vitreous; Hirschberg {vide "Virchow, I.e.) observed in the 
retina the remains of an inflammatory affection and sudden cylin- 
drical swelling of the two veins which pass outward, with rosary- 
like expansions. 

Flashar {Berl. kl. Woeh., 1880, No. 31) describes a double 
neurotic facial atrophy ; upon the side which was most affected the 
reaction of the pupil was lost, and there was divergent strabismus, 
with amblyopia and atrophy of the optic nerve. 

According to Nothnagel {Neiir. CentraJhl.^ 1891, p. 320) there 
are two forms of facial hemiatrophy, one due to lesions of the sym- 
pathetic, the other to lesions of the trigeminus ; the latter have been 
demonstrated anatomically. Id my opinion both nerves are always 
affected, although the lesion of one sometimes predominates, some- 
times that of the other. 

3. Diseases of the Nerves. 

Diseases of the peripheral nerves rarely affect the eye, unless they 
belong to that organ or are adjacent to it. 

Multiple Neuritis^ 

i.e.., more or less acute interstitial inflammation of the nerves, giving 
rise to secondary degeneration and finally atrophy of the nervous 
elements, occurs occasionally after all forms of infection. It develops 
after poisoning, especially of a chronic character (arsenic, alcohol, 
lead, etc.), after acute (typhoid fever, influenza) and chronic infec- 
tious diseases (syphilis, general carcinosis, etc.), as the result of 
constitutional anomalies (diabetes) or organic diseases (cirrhotic 
kidneys). It may even constitute the principal symptom of an in- 
fectious disease, as in beri-beri or kakke. The symptoms vary ac- 
cording as the anterior or posterior roots, the nerve plexuses or the 
peripheral nerves are chiefly affected. 

When the posterior roots of the spinal nerves are most involved, 
especially if the inflammation is ascending in type, the symptoms 



DISEASES OF THE NERVOUS SYSTEM. 205 

may be very similar to those of tabes (pseudo-tabes) . As a general 
thing the course is more rapid than that of true tabes. If it begins 
acutely with fever and with parsesthesiae and pains which pass rapidly 
into ansesthesise and motor disorders, a mistake is hardly possible. 
But if the inflammatory process in the nerve roots runs a very chronic 
course, a differential diagnosis may be very difficult, unless aided by 
the etiology or certain eye symptoms. 

Any disturbance of vision which may be present depends mainly 
upon an axial neuritis of the optic nerve, and consists of central sco- 
toma with color disturbance which is so characteristic of toxic ambly- 
opia. This does not occur in tabes, or, at least, very rarely. Other 
forms of visual disturbance are rare. The ophthalmoscope also shows 
the findings which are characteristic of toxic amblyopia, viz., gray- 
ish-red opacity and obliterated borders of the inner (nasal) half of the 
optic nerve, with atrophic discoloration of the outer half where the 
fibres to the macula lutea are located. These findings may also be 
present without any notable disturbance of vision. 

The absence of true spinal symptoms, particularly myosis and re- 
flex rigidity of the pupil, is also characteristic of multiple neuritis. 
Other paralyses of the ocular muscles may be present if the nerves 
at the base of the brain are attacked. Nystagmus is rare because it 
does not follow inflammation of the nerves and must result from com- 
plications. 

If the anterior roots are mainly attacked, we find stationary and pro- 
gressive (amyotrophic) muscular paralyses, which are distinguished 
with difficulty from those due to an affection of the anterior horns of 
the spinal cord. This category includes acute ascending paralysis 
(Landry's paralysis), which may occur as a primary affection of the 
cord or as a primary multiple neuritis. Ocular symptoms are only 
present accidentally and cannot be utilized in differential diagnosis. 

Oculo-pupillary symptoms occur in the inferior type of combined 
amyotrophic paralysis of the arm (paralysis of the hand, forearm and 
triceps, with pronounced affection of sensation) if the nerve roots or 
the spinal cord itself have been implicated. The oculo-pupillary fibres 
from the cord to the sympathetic pass through the seventh and eighth 
cervical and first dorsal nerve roots. If these become impermeable. 



206 THE EYE IN RELATION TO DISEASE. 

ptosis, myosis and enophthalmus, either separately or in combination, 
will be present on the same side. If they are the site of spasm or 
neuralgia, spastic mydriasis is often noticed, with or without dilata- 
tion of the palpebral fissure and exophthalmus. If the affection is 
located peripherally in the brachial plexus, these symptoms will be 
absent because the plexus proper no longer contains oculo-pupillary 
fibres. 

In the superior type (shoulder-arm paralysis, without notable 
disturbance of sensation), vasomotor disturbances are often seen in the 
face, if the nerve roots have been involved. They are absent in pure 
paralysis of the plexus. 

Diseases of the Trigeminus. 

a. Inflammations of the first branch of the trigeminus, extending 
to its terminal ramifications, may give rise to herpes. In addition 
to neuralgic pains there is more or less disturbance of sensation and 
even complete anaesthesia. For the sake of convenience the different 
forms of herpes of the eye will be discussed in the chapter on diseases 
of the skin. The infectious inflammations of the cornea which often 
attend herpes may also present the signs of neuro -paralytic keratitis. 

In one case of herpes zoster ophthalmicus Daguenet {Rec. 
d^Ophth., 1877, p. 117) found optic neuritis with swelling, exudation 
and very sinuous veins, later, atrophy of the optic nerve with V = |-. 
It is possible that the ophthalmoscope would furnish positive re- 
sults more often than is generally assumed. But hypersemia of the 
fundus must not be regarded as of special importance, because it is due 
to the diminution of intraocular pressure which is usually present. 
Paresis and paralysis of accommodation and mydriasis have been 
observed repeatedly. Uhthoff (Jahr. f. Aug., 1886, p. 459) noticed 
cessation of the lachrymal secretion in neuritis of the trigeminus. 

b. The ocular branches may take part in trigeminal neuralgia, 
and then redness of the conjunctiva, increased lachrymal secretion, 
slight swelling of the lids, photophobia, etc., are frequent symptoms. 
On the other hand the pains (ciliary pains) may radiate into other 
branches of the trigeminus. 

In all neuralgias, but especially in those of the trigeminus, dilata- 



DISEASES OF THE NERVOUS SYSTEM. 207 

tion of the pupil is often found corresponding to the mydriasis after 
cutaneous irritation. In a case of severe neuralgia of the first and 
second branches of the nerve, Gerbardt {Arch. f. kl. Med. , XVI, 1 
and 2) found slight hypersemia of the retina and an arterial pulse in 
the eye on that side. 

c. A very interesting affection is the so-called neuro-paralytic 
keratitis which occurs in anaesthesia of the trigeminus. This is a 
form of progressive infectious corneal ulcer which is peculiar in 
several respects. Man}- regard it as a proof of the existence of special 
trophic fibres in the first branch of the trigeminus. 

In anaesthesia of the cornea it is very often found that ulcerative 
keratitis develops spontaneously, after a longer or shorter period, in 
the exposed part of the cornea. The ulcer becomes infected, enlarges 
slowly but constantly, and may lead to complete destruction of the 
cornea. It may also recover at any stage, particularly when the 
anaesthesia disappears. The course is peculiarly asthenic; the in- 
flammatory reaction of surrounding parts is absent or abnormally 
slight, and this is evidently the cause of the peculiar progressive 
course. Similar affections are observed in herpes cornese, starting 
from the ulceration, and occasionally in Basedow's disease. In both 
cases the cornea is usually insensible. A similar condition is found 
in the marantic or desiccation keratitis after the profuse diarrhoea 
of childhood, cholera, etc. 

Special trophic fibres in the trigeminus have been very generally 
assumed in explanation of this peculiar course of neuro-paralytic kera- 
titis. It was found that the inflammation did not develop when the 
innermost fibres of the trigeminus were spared on section of the 
nerve (Meissner). According to Gaule the condition does not 
develop if any fibres escape; he assumes that this is owing to the 
fact that under such circumstances the sensibility of the cornea is 
subsequently restored. 

Neuro-paralytic keratitis occurs only in peripheral anaesthesias of 
the trigeminus and also after destruction of the Gasserian ganglion. 
It does not develop when sensory conduction is interrupted cen- 
trally (Magendie), even after the cornea has been entirely insensible 
for years. 



208 THE EYE IN RELATION TO DISEASE. 

Snellen advanced the first weighty argument against the exist- 
ence of special trophic nerves. He showed that the disease does not 
develop when it is possible to protect the cornea against all external 
irritants and injuries. 

Ferrier {Lancet, 1888), who observed neuro-paralytic keratitis in 
anaesthesia dolorosa, regards the former as an irritative condition 
analogous to the latter. But we are hardly warranted in regarding 
a purely functional disorder (pain) as co-ordinate with a very mate- 
rial anatomical change. 

Gaule {Centralhl. f. Physiol., 1891, p. 15) has recently described 
visible changes in the corneal corpuscles and circumscribed necroses 
and foci of proliferation of the epithelial cells, which follow immedi- 
ately upon division of the trigeminus. He attaches great importance 
to the consequent disturbance of the nutritive currents in the cornea, 
giving rise to an insufficient supply of fluid to the cornea and to relative 
dryness. This is favored still more by the insufficient winking 
movements. He denies the existence of special trophic fibres, because 
no centrifugal fibres pass to the cornea. He regards the corneal cor- 
puscles as the terminal organs (preferably organs of origin) of the 
sensory fibres. After division of a sensory nerve its cells of origin 
at the periphery are destroyed in the same way that the cells of ori- 
gin in the muscle nucleus degenerate after division of a motor fibre. 

Two points must be kept in mind: 1. The interruption must be 
situated in the peripheral nerve. 2. The disease does not develop if 
an external injury to the cornea with loss of substance can be avoided. 
We may state, accordingly, that neuro-paralytic keratitis is an in- 
fectious inflammation resulting from a traumatic loss of substance in 
the cornea, and which runs a peculiar course on account of the inter- 
ruption to conduction in the centripetal nerve tracts. 

The nutrition of the uninjured cornea is evidently not impaired on 
account of its insensibility, but under pathological conditions the 
corneal tissue reacts differently. The absence of vessels is the 
ground of the difference between the cornea and other tissues. If 
infection occurs after a loss of substance in a vascular tissue, its 
products act directly on the vessels and produce the well-known 
changes which lead to stasis, emigration of white blood globules, etc. 



DISEASES OF THE NERVOUS SYSTEM. 209 

In the cornea, when rendered insensible from peripheral causes, this 
takes place only to a slight extent, and only becomes more marked 
when the process approaches its margin (demarcating inflammation) . 
In the normal cornea the stimuli which are conveyed centripetall}^ 
evidently act upon sympathetic ganglion cells, whence a direct influ- 
ence is exerted upon the vessels of the adjacent tissues, particularly 
the conjunctiva. In normal nutrition this influence is less prominent 
because it takes place mainly from the intraocular tissues (uvea); 
the vascular reflexes in question are perhaps presided over by the 
ciliary ganglion. In pathological processes, on the other hand, in 
which the vascular tract of the conjunctiva is chiefly affected, the 
case is different. The vascular changes in the conjunctiva which 
occur in infectious inflammation of the cornea are greatly di- 
minished or abolished when the sensory conduction between the 
cornea and sympathetic is interrupted. 

Moreover, the corneal corpuscles from which the regeneration of 
the destroyed tissue must take place become necrotic, as Gaule has 
shown, after division of the trigeminus. Hence, the regeneration 
is only possible from the cells of the conjunctiva, and as a matter of 
course takes place very slowly, particularly in complete anaesthesia 
of the entire cornea. It will take place much more readily if con- 
duction alone is interrupted while the nerve fibres remain intact. In 
the latter event the corneal corpuscles probably also remain intact. 

Whether the centripetal stimuli reach consciousness is immaterial. 
It is sufficient that they be conveyed to the ganglion cells of the 
sympathetic. An equally slight influence is exerted when centrifugal 
sympathetic conduction is interrupted centrally from the sympathetic 
ganglion, as happens in the oculo-pupillary and vasomotor sympa- 
thetic paralyses which are located in the cord, the roots of the spinal 
nerves, or the sympathetic ganglion. In such paralyses the nutrition 
may remain unimpaired for years, and the reaction of the tissues to 
pathological irritants likewise appears to be unchanged. It is evident 
that the conduction between these " central" sympathetic centres and 
the terminal ramifications of the sympathetic nerves is interrupted 
by ganglion ceUs of a lower order. 

The case is different when the sympathetic ganglion cells are 
14 



210 THE EYE IN RELATION TO DISEASE. 

diseased but not destroyed. A direct, continuous and anatomical 
change in the cellular elements of the vessels — with which the endothe- 
lium of the corneal corpuscles is co-ordinate — is then produced. In such 
cases the pathological findings are : dilatation of the vessels, changes 
in the endothelium together with the tissue changes observed after 
inflammatory irritants (accumulation of round cells, proliferation of 
the tissue cells, and formation of cicatricial tissue). If vascular 
tissues become anaesthetic, the altered reaction to injuries and in- 
fected lesions is less striking, but often distinctly noticeable. 

These statements harmonize very well with our knowledge con- 
cerning the so-called trophoneuroses : — the frequent initial symptoms 
of irritation of the sympathetic nerves, often terminating in paral- 
ysis; the onset with ansesthesise and parsesthesise ; or the predomi- 
nance of sensory or of sympathetic symptoms in the same disease (uni- 
lateral facial hemiatrophy, starting rarely from the trigeminus, more 
frequently from the sympathetic) ; or the fact that in the same disease 
(syringomyelia) trophic disorders may be either present or absent (ac- 
cording as the process has involved the intervertebral ganglia or has 
remained confined to the spinal cord), etc. Such trophic disturb- 
ances and abnormal reaction to external (probably also internal) 
noxious influences are found whenever the sensory (centripetal) con- 
duction to the sympathetic ganglion, the latter itself, or its centrifugal 
fibres to the tissue cells of the vessels (macular fibres and endothe- 
lium) are interfered with. Symmetrical affections will develop when 
a spinal lesion extends to the nerve roots and to the spinal ganglia of 
both sides at the same level ; for example, symmetrical gangrene in 
syringomyelia. It is well known that in primary disease of the 
vessels the developmental and nutritive conditions are abnormal, and 
the reaction to inflammatory and other irritants is different from 
that in other localities in which the vessels are healthy. In all these 
cases there is either an imperfect transmission of sensory stimuli to 
the centrifugal sympathetic fibres or a disturbance in the latter, in- 
cluding their origin (ganglia) and terminations (walls of the vessels). 

If the term trophic nerve fibres is to be used at all, it should be 
applied to the peripheral ramifications of the vasomotor nerves, and 
these are absent in the cornea. This is the very reason of its pecu- 



DISEASES OF THE NERVOUS SYSTEM. 211 

liar reaction after peripheral interruption of its centripetal sensory 
conducting tracts. 

It is evident that desiccation of the surface plays no great part in 
ordinary neuro-paralytic keratitis because the latter is unilateral in 
the great majority of cases. 

Winking occurs uniformly on both sides, even if one eye is in- 
sensible. But in the so-called marantic keratitis, in the corneal ul- 
ceration of Basedow's disease, the insufficient moistening and super- 
ficial desiccation are important. 

Collins' case {Brit. Med. Journ., June 23d, 1888) of unilateral 
cataract upon the side of a complete trigeminal anaesthesia, while the 
conjunctiva and cornea remained normal, is unique. Perhaps it was 
a mere coincidence in an hysterical anaesthesia. 

Diseases of the Facial Nerve. 

In peripheral facial paralyses and spasms, not confined to single 
branches, the external ocular muscles supplied by the nerve are con- 
stantly affected. In central affections the so-called ocular facial (orbi- 
cularis palpebrarum and frontalis) is often not involved, in others it 
alone is affected (page 23). 

Guinon (Rev. de Med., 1887, No. 6) found concentric narrowing 
of the field of vision in convulsive tic. The former is not due to 
the latter, but both are probably symptoms of the same nervous 
affection. 

4. Functional Neuropsychosis. 

This term includes a series of diseases of the nervous system in 
which material anatomical findings are absent, or, if present (as in 
chorea), act only as an indirect cause by remote action upon the nerve 
fibres and cells. The findings in the eye have an unmistakable sim- 
ilarity in all these diseases. We will devote our attention mainly to 
concentric narrowing of the field of vision with or without color 
disturbance and with or without disturbance of central vision. 
This is evidently a peripheral disorder of conduction in the optic 
nerve. 



212 THE EYE IN RELATION TO DISEASE. 

Hysteria. 

As a matter of course eye symptoms are not wanting in the varied 
clinical history of hysteria. They include disturbances of sight, 
paralyses and spasms, disorders of sensation and secretion, peculiar 
associated sensations {audition coloree) and the like. 

a. Disturbances of sight ; bilateral or, much more often, unilat- 
eral amaurosis. The reaction of the pupil to light may be retained or 
lost ; its size often changes without known cause. The ophthalmo- 
scopic appearances are normal. In unilateral blindness with intact 
reaction of the pupil to light we may be led to suspect simulation, 
especially if simulation tests show that the apparently blind eye pos- 
sesses normal vision when the patient thinks he is seeing with the 
good eye, and also that the good eye is blind when he believes that 
he is using the blind eye (for example, in tests with prisms or the 
stereoscope). In such cases the presence of other undoubted hj^steri- 
cal symptoms may be very important. Such cases undoubtedly oc- 
cur, but it may be very difficult to make a differential diagnosis be- 
tween unilateral hysterical blindness and simulation, even if the 
individual has not the slightest object in simulation. 

Unilateral amblyopia is much more common than complete blind- 
ness, but double amblyopia is much rarer. The amblyopia occurs as 
retinal anaesthesia (page 32), a more or less marked concentric nar- 
rowing of the field with or without impairment of central vision and 
with or without disturbance of the color sense corresponding to the 
narrowing of the field of vision. This may even proceed to color- 
blindness and total color-blindness, but then central vision is usually 
more or less impaired. 

In hysterical disorders the boundaries for the different colors may 
be entirely abnormal ; red is recognized farther toward the periphery 
than yellow, etc., or the curves of the different colors cross one an- 
other. A large part of these anomalies is explained by the sudden de- 
velopment of the affection. If, coming suddenly, red, orange yellow 
and yellowish- green are perceived in the same intensity of shade, it 
makes no difference which name I apply to any of these colors ; if 
the same disorder of color sense develops slowly and gradually, cer- 



DISEASES OF THE NERVOUS SYSTEM. 213 

tain data for differentiation are furnished (viz., optic atrophy). But 
this explanation does not suflQce for all cases. Some resemble the 
"disorder of the perception of colors" (page 33), and others mock all 
efforts at explanation. 

According to Charcot a characteristic sign of hysteria is the uni- 
lateral concentric narrowing of the field of vision with more or less 
impairment of central vision and of color preception (v. Graefe's an- 
aesthesia retinse, vide Leber, " Handb. d. Aug.," V, p. 980; Foer- 
ter's kopiopia hysterica, ibid., ^^H, P- 89). It is usually onh^ a fea- 
ture of a general hemiansesthesia of the same side ; occasionally this 
is confined to the face and neck. As a rule it is associated with an- 
aesthesia of the conjunctiva and cornea, but the latter never termi- 
nates in neuro-paralytic keratitis. According to Fere, anaesthesia of 
the conjunctiva is always present, but this statement is probably 
exaggerated. 

If the amblyopia is bilateral it is more pronounced, according to 
Charcot, on the side of the hemianaesthesia. According to Gilles de 
la Tourette, hysterical disorders of vision are always bilateral, but 
are almost always more marked on one side. 

The same remarks hold good in regard to examining for simula- 
tion in hysterical amblyopia as have been made above concerning 
hysterical amaurosis. According toMoravesik {Neurol. Centralhl., 
1890, p. 230) peripheral stimuli, such as dropping ether upon the 
arm, etc. , enlarge the visual field by a few degrees ; joy enlarges, sor- 
row contracts it, etc. Vision can sometimes be improved by wear- 
ing an 3^ kind of glasses (if they do not diminish vision for distance), 
evidently by arousing a certain amount of innervation on the part of 
the patient; plane glasses, weak prisms, etc., are often sufficient for 
this purpose. 

According to Charcot hemianopsia does not occur in hysteria; 
hence scintillating scotoma (ophthalmic migraine) is only an acci- 
dental symptom; it occurs in the hysterical as often as in the non- 
hysterical. Landolt has observed hemianopsia, however, and in one 
of his cases, unilateral amblyopia had been diagnosed by others. His 
cases were not pure, however, because the ophthalmoscope showed 
abnormal findings. Glorieux {Jahr. f. Aug., 1887, p. 295) reports 



214 THE EYE IN RELATION TO DISEASE. 

a case, in a boy aged sixteen years, of right hemiansesthesia and tem- 
porary right hemianopsia. Rosenstein (Centralbl. f. Aug., 1879, p. 
351) observed a bitemporal hemianopsia. But such cases are so rare 
that we are inclined to suspect a complication. 

Hallucinations also occur and are very similar to those of alco- 
holism. They are, correctly speaking, illusions and are due to a false 
interpretation of objects perceived entoptically. 

A rarer hysterical symptom is unilateral or bilateral diplopia or 
monocular polyopia without corresponding findings. No sufficient 
explanation has yet been offered, although there is much in support 
of the assumption of partial or irregular contraction of the ciliary 
muscle (Charcot and Parinaud). Astigmatism may be produced 
in the same way. (Borel, Arch. f. Aug., 1886, p. 253). [A case of 
monocular polyopia in each eye, sometimes passing into tetropia, be- 
cause the two eyes did not always co-ordinate in their movements, 
came under my notice. It was due to astigmatism, combined with 
latent strabismus convergens, in an extremely hysterical woman. 
By suitable glasses, both cylindric and prismatic, and general treat- 
ment the symptoms were removed. — Ed.] Photopsia, hemeralopia, 
unilateral hemianopsia {?), micropsia (paresis of accommodation), 
macropsia (spasm of accommodation), scotoma, etc., have also been 
reported, but they are not at all characteristic of hysteria. Finkel- 
stein {Jahr. f. Aug., 1886, p. 292) claims to have seen two cases of 
paracentral scotoma, similar to that of Hirschberg's alcoholic am- 
blyopia. 

Occasional mention is made of colored hearing (audition color ee) , 
i.e., certain letters, tones, or words, when heard, produce a coinci- 
dent sensation of color. A still rarer condition may be called 
"sounding vision," in which the sight of certain colors produces a 
certain perception of sound. 

Hysterical disorders of sight almost always begin suddenly, may 
last for any length of time, and usually disappear suddenly. 

h. Among the muscular disorders of the eye, spasms are frequent 
while paralyses are remarkably rare. Duchenne {Gaz. des Hop., 
1875, p. 682) observed only one case of hysterical paralysis of an eye 
muscle; in addition to other paralyses there was temporary paresis 



DISEASES OF THE NERVOUS SYSTEM. 215 

of the right, and later of the left abducens. Double abducens pare- 
sis is also mentioned in Roeder's case (Monatshl. /. Aiig.^ Nov., 
1891). Moebius denies the occurrence of paralysis of the eye muscles 
in hysteria, and regards them as traumatic. 

Besides paresis of the abducens, uncomplicated ptosis occurs in 
hysteria. Schaefer finds it {Arch. f. klin. Med.^ Bd. V) a frequent 
symptom of hysteria in children. 

This restriction of hysterical paralysis to unilateral or bilateral 
abducens paresis and ptosis furnishes food for thought. It appears 
much more probable to me — although I have not seen such cases — 
that the abducens paresis should be called a spasm of convergence. 
If we may also regard, as is extremely probable, the ptosis as the re- 
sult of paralysis of the sympathetic (perhaps of spasm of the orbicu • 
laris) then we would be justified in maintaining that paralysis of 
single external muscles of the eye does not occur in pure hysteria. 
Slight paresis of all the external muscles may in reality be a condition 
of slight spasm ; in both cases the mobility in all directions is mod- 
erately impaired. 

Pareses and paralyses seem to occur in the smooth internal muscles 
of the eye, especially the ciliary muscle, although the diagnosis is 
not alwa3'S easy. For example, in marked concentric narrowing of 
the field with diminution of central vision and spasm of the sympa- 
thetic, it is not justifiable to conclude forthwith that immobility of 
the iris to light is due to paralysis of the sphincter pupillae. 

Tonic and clonic spasms of the orbicularis palpebrarum (blepha- 
rospasm) are often observed ; they may or may not be attended with 
pain. Some of the cases described as ptosis are probably due to spasm 
of this muscle. Spasm of accommodation often combined with ma- 
cropsia is also observed. 

An occasional symptom is spastic contraction of both internal 
recti (spasm of convergence) . We have already observed that many 
so-called abducens paralyses may be attributed to the same condition. 

Constant twitching of the upper lids, repeated about twice a 
second, is said to be a very characteristic sj^mptom. It is probably 
due, like nystagmus, to weakening of the motor cortical innervation 
to the muscles. 



216 THE EYE IN RELATION TO DISEASE. 

Apart from hystero-epileptic seizures, conjugate deviation is rare 
(Griffith, Jalir. /. Aug., 1888, p. 416, 2 cases; Forst, ihid., 1884, p. 
680). 

Variations in the size of the pupils, without known cause, is said 
to be quite frequent. In Donath's case {Neurol. Centr., 1892, p. 
156) there was periodical hysterical paralysis of the pupils and ac- 
commodation, which was cured by hypnotism. It is doubtful whether 
the case belongs to this category, because atropine was found in the 
possession of the patient. Eapid changes in the fulness of the ves- 
sels of the iris may be the cause of this pupillary symptom. 

The membranes of the eye may also be " hysterogenic'* and con- 
tact with them may provoke attacks. According to Gilles de la 
Tourette {Ann. d'Oc, Oct., 1891, p. 266) this is true of the conjunc- 
tiva, cornea, inferior lachrymal duct and the mucous membrane of 
the lachrymal sac. 

c. Among the disorders of sensation, anaesthesias of the integu- 
ment of the temples and eyelids, of the conjunctiva and cornea, are 
quite frequent, and may be associated with retinal anaesthesia. Con- 
tact with the insensible cornea may provoke an abundant secretion of 
tears (Gilles de la Tourette). It has been maintained that the pupil 
on the anaesthetic side is larger than on the other, but this is not true 
of all cases. According to Fere the iris on the anaesthetic side has a 
darker color, and this does not change on transfert (that is, when by 
the influence of suggestion abnormal sensations are transferred to 
the opposite side of the body), but there are also frequent exceptions 
to this rule. 

Paraesthesiae of all kinds are often observed in the eye. Hyper- 
aesthesia of one side of the face, including the lids, conjunctiva and 
cornea, and with or without photophobia, is also a frequent symptom. 
Vision in the hyperaesthetic eye is sometimes increased. 

Pains around and within the eyes are very common. Apart from 
all the forms of migraine, which possess no characteristic features, 
the most frequent are the so-called ciliary pains, i.e., pains in the 
eye radiating toward the forehead, temple, teeth, etc., and occurring 
spontaneously or after attempts at accommodation. The region of 
the ciliary body is sometimes tender to the touch, as in cyclitis. Al- 



DISEASES OF THE NERVOUS SYSTEM. 217 

though these pains render almost every function of the eye impossible 
and are extremeh' intractable to treatment, nothing is found objec- 
tively. These " ciliary pains without findings" constitute a part of 
Foerster's kopiopia hysterica. They are identical with Donders' 
painful accommodation, iSTagel's hypersesthesia of the ciliary muscle, 
Schenkl's hysterical eye pain, and Horner's neuralgia bulbi. 

d. Among the principal disorders of secretion may be mentioned : 
epiphora without discoverable cause (frequent), disorders of the sweat 
secretion, blue sweat (chromhidrosis) , particularly of the ej^elids, etc. 
The so-called oedeme bleu des hysteriques is oedema combined with 
dilatation of the vessels. 

These symptoms may occur in every possible combination. They 
usually begin suddenly and disappear in the same way ; they change 
from the right side to the left, and may last a very short or verj- long 
time. When unilateral, they may usually be made to disappear and 
be transferred to the other side (transfert) by means of various man- 
ipulations, such as contact with a magnet, with certain metals, etc. 

Ej^e symptoms, particularly the unilateral concentric narrowing 
of the field of vision, may be produced by touching certain parts of 
the skin with vibrating tuning-forks, or, when present, these symp- 
toms may be cured by looking through colored glasses, etc. 

While the absence of objective findings is characteristic of all 
hysterical affections, it is to be noted that occasionally we find trophic 
disturbances, such as hemorrhages, vesicles on the skin, falling out 
of the nails and hair, etc. This furnishes a certain relationship to 
diseases of the sympathetic, in which these symptoms occur more 
frequently. Atrophic processes in the muscles, which could hardly 
be attributed to disuse, have also been reported. 

Leber has also found objective changes in the optic nerve in the 
amblyopia with concentric narrowing of the field which, according 
to Charcot, is characteristic of hysteria. On account of the impor- 
tance of these findings with regard to the theory of hysteria, I here 
reproduce Leber's report : 

"A woman, set. 45 years, from Griesinger's cliDic. Amblyopia hysterica 
without ophthalmoscopic changes. R. , hardly fingers at 1'; L., M. i, Jaeger 
No. 5, with difficulty. Concentric narrowing of both visual fields. Slight 
double abducens paresis (spasm of convergence?). Anaesthesia of the left side 



218 THE EYE IN RELATION TO DISEASE. 

of face, at times complete left liemiansesthesia, and weakness of the left side of 
the body. Death from septicaemia after removal of a small tumor in the left 
axilla which was falsely regarded as a neuroma. Post-mortem findings negative 
as regards the primary disease. The optic nerve, chiasm and tractus appeared 
entirely normal to the naked eye ( !) . After hardening, transverse section of both 
optic nerves immediately in front of the chiasm showed a narrow gray band, 
which did not stain with gold, and consisted of nerve bundles which in part 
were entirely atrophic, in part contained a few medullated fibres among the non- 
meduUated, atrophic fibres. The other nerve bundles stained uniformly with 
gold, but on teasing, a few atrophic fibres were found, and also some amyloid 
corpuscles. Nearer to the eyeball a series of sections showed a somewhat lighter, 
more yellowish color, starting at the periphery, and this was gradually lost. 
Hardly any changes were found here with the microscope. In the tractus a 
moderate number of amyloid corpuscles were imbedded in a very thin, super- 
ficial layer, composed of fibres running in a somewhat circular direction ; in this 
region the pial sheath was infiltrated quite abundantly with lymph corpuscles, 
which also filled the perivascular spaces. On account of the mild grade of these 
changes it wasdifiicult to ascertain their extent and mode of development. The 
impression produced was that of a nutritive disturbance of the superficial bundles 
starting from a slight perineuritis. This was entirelj" inadequate to explain the 
marked amblyopia. " (The changes found by Leber evidently exceed the slight 
atrophy of the peripheral bundle of the optic nerve which, according to Fuchs, is 
constantly present) . 

I regard these positive anatomical findings as extremley impor- 
tant. While the motor, sensory and secretory symptoms of hysteria 
permit only a qualified local diagnosis, a positive diagnosis may be 
made of the location of the visual disorder which, according to Char- 
cot, is characteristic of hysteria. This disorder is identical with that 
observed in interference with conduction in the optic nerve, and its 
frequent unilateral occurrence proves that it is peripheral in origin. 
In the entire central organ beyond the entrance of the optic nerve 
into the chiasm there is no locality in which a lesion can produce 
unilateral disturbance of vision. 

As hysterical symptoms have been generally regarded as central, 
Charcot and his pupils have been led to assume a decussation of the 
uncrossed optic nerve fibres behind the chiasm and the primary optic 
ganglia, in order to explain unilateral visual disorders by central 
causes. Such an assumption is anatomically indefensible. Lanne- 
grace also assumes an action upon the vessels of the eye, not upon 
the optic fibres, in the unilateral visual disorders which he produced 
experimentally by certain injuries of the brain. 

Even if the cause of the visual disorder per se is central, it acts 



DISEASES OF THE NERVOUS SYSTEM. 219 

peripherally upon the organ of sight at the spot close to the chiasm 
where Leber found the periphery of the optic nerve atrophic and many 
nerve fibres destitute of medulla. This finding appears to me to be 
entirely sufficient to explain the visual disorder. The absence of visi- 
ble ophthalmoscopic changes is explained by the fact that the fibres 
are not destroyed but that the medulla is wanting in places; in addi- 
tion the central artery of the retina enters the optic nerve much far- 
ther forward. As a result of the absence of the medullary sheath 
the conduction to the central organs is interfered with or abolished. 
The condition is similar to that of the degenerated patches in multiple 
sclerosis. In the latter affection the ophthalmoscopic appearances 
may also be negative or be entirely disproportionate to the severity 
of the disorder of vision, even though the sclerotic focus is situated 
immediately behind the entrance of the nerve into the eye. In hys- 
teria, however, the peripheral bundles of the optic nerve are mainly 
affected, in multiple sclerosis the axial bundles. 

We moreover find symptoms of pressure on the nerve at the point 
of passage through the optic foramen. The importance of the bony 
foramina through which nerves pass has long been known. If it 
happens in the optic nerve, why may not peripheral pressure symp- 
toms in other nerves be produced during their passage through nar- 
row bon}" canals? Macroscopically these changes might be invisible, 
but under the microscope they would appear as partial absence of the 
medullary substance and finally slight atrophy. During life these 
changes might be much more marked than after death, when the 
pressure, especially that exercised by the vessels, becomes much less. 
It is hardly the result of pure accident that those nerves which do 
not pass through bony canals, viz., the motor nerves of the eye, are 
so very rarely or never affected by hysterical paralysis. 

As each side of the body has its own vasomotor nerves, the possi- 
bility of unilateral disorders is thoroughly assured. 

1. If we assume that the peripheral nerves at the point where they 
pass through bonj^ canals are by very slight pressure made incapable 
of conducting peripheral stimuli to the central nervous system or of 
conveying motor impulses in the opposite direction, this constitutes 
a predisposition to hysteria. On account of the pressure the fiuid 



220 THE EYE IN RELATION TO DISEASE. 

medullary substance will be pressed away in the unyielding bony 
canal. On account of the consequent impairment of conduction the 
transmission of stimuli will be interfered with to a greater or less ex- 
tent or even abolished. It is also possible that a centripetal stimulus 
may be conveyed to the primary ganglia but is too weak to reach the 
cortex (consciousness), for example, in unilateral hysterical amaurosis 
with normal reaction of the pupil to light. The favorable result of 
rest cure in hysteria supports, to a certain extent, the theory of an 
insufficient amount of medullary substance in the nerves, although, 
as a matter of course, this does not constitute a proof. 

Under such circumstances the sudden appearance and disappear- 
ance of symptoms, with complete restoration of function, would be 
easily explained ; and the phenomenon of transfert would also be un- 
derstood more readily. It would be equally plain that, after pro- 
longed duration, nutritive disturbances and changes may develop, 
particularly in the nerves themselves. 

It is well known that the function of the peripheral nerves, as well 
as that of the fibres of the central nervous sj^stem, does not begin un- 
til they acquire a medullary sheath. In different nerves and systems 
of fibres this takes place at different periods of foetal life or only after 
birth. The investigation of such conditions has been very important 
in regard to our knowledge of the anatomy of the central nervous 
system (Flechsig) . It is also well known that when the axis cylinders 
of the nerves are intact but the medullary sheath is wanting in places 
(sclerotic patches in the optic nerve, Uhthoff), the function of the 
nerve may be notably impaired or even abolished, without correspond- 
ing ophthalmoscopic findings. This disturbance of function can 
only be due to imperfect isolation of nerve conduction, and in fact 
the oils, among which the medullary substance must be included, 
have been found to be the best insulators for the electrical current. 

This assumption of disturbed function by imperfect isolation pre- 
supposes conduction in the nerves in two directions, and this really 
appears to take place. In sensory nerves the centripetal conduction, 
in motor nerves the centrifugal conduction, takes place in the axis 
cylinders, the return conduction in the neuroglia. It has been proven 
anatomically and experimentally that the optic nerve, which really 



DISEASES OF THE NERVOUS SYSTEM. 221 

constitutes a part of the brain, contains an approximately equal num- 
ber of centrifugal and centripetal fibres {vide p. 13). If the insulat- 
ing medullary substance is removed at any part, the same condition 
is created as in the grounding of a telegraph wire ; the current only 
flows between the point of irritation (or stimulation) and the point 
of interruption. If the break is not complete, further conduction is 
always considerably weakened or takes place only when the current 
is unusually strong, etc. If the break takes place, for example, in 
the intervertebral foramina, sensory stimuli will no longer be con- 
veyed to the cord, but they may still give rise to the external reflexes 
in the domain of the sympathetic nerve. Motor impulses will not 
only fail to reach the muscles but will also exert no influences on the 
vasomotor nerves. 

2. " The predisposition" is sometimes supplemented by slight ex- 
citability of the vasomotor system in whole or in part, — for example, 
the reflex inhibitory influence of the central organs upon the vaso- 
motor nerves may be enfeebled or abolished and the vascular reflexes 
thus increased. All the conditions are then furnished which are 
necessary to explain the larger part of hysterical symptoms. We 
can also understand how hysteria may suddenly develop, if the pre- 
disposition is present, after an injury, a stroke of lightning, a fright, 
etc. It is only necessary that comparatively trifling causes should 
produce contraction or dilatation in certain of the larger or smaller 
vessels, to a degree insufiicient to interfere notably with nutrition, 
but sufficiently' pronounced to interfere with or abolish conduction in 
certain nerves. 

These vascular changes may affect any part of the nervous system 
and, as the result of increased or diminished supply, may give rise 
to abnormal nutrition and to consequent increased or diminished ex- 
citability to centripetal stimuli and to increased or diminished centri- 
fugal innervation. The points of predilection are evidently the nerves 
which pass through canals, where an enlargement of the vessels is 
apt to give rise to interference with or abolition of conduction. If, 
in a case of unilateral disorder from dilatation of the vessels (for ex- 
ample, hemiansesthesia), a comparatively slight stimulus (application 
of a metal or magnet) is employed, this may give rise, on account of 



222 THE EYE IN RELATION TO DISEASE. 

the increased vascular reflexes, to contraction of the vessels and thus 
to restoration of conduction. This may even give rise to dilatation 
of the vessels at the corresponding part of the opposite side of the 
body and thus produce the phenomenon of " transf ert, " but the condi- 
tions are not always so simple. 

I have purposelj^ spoken of contraction and dilatation of the ves- 
sels, not of spasm and paralysis. The latter will produce much more 
severe symptoms, but as a matter of course it is difficult, and often 
impossible, to draw a sharp line between them. Moreover, transitions 
also occur, as, for example, from hysteria to epilepsy. On the other 
hand, the transition of purely functional hysterical conditions into 
trophic disorders has also been occasionally observed. 

Apart from its conduction to the central organs, every peripheral 
stimulus exerts a direct influence on the vessels of the irritated part. 
Each function may be disturbed independently of the other. In addi- 
tion to other " reflex inhibitory" fibres, the central organs contain some 
which have a tonic action on the vessels and inhibit the direct vas- 
cular reflexes. It is well known that the exclusion of an entire cere- 
bral hemisphere also causes symptoms of unilateral sympathetic 
paralysis in the face, and particularly ditatation of the vessels. If a 
sensory stimulus is not conveyed to the central organs, we shall find, 
in addition to the disturbance of sensation, increased vasomotor re- 
flexes, a very frequent symptom of hysteria. 

If a paralysis has lasted for some time, the conviction of the im- 
possibility of performing the movement may become so firm that it 
can no longer be innervated spontaneously even if conduction has 
been restored. In such cases the movement would be possible as an 
involuntary reflex. 

It is also conceivable that, despite the existing interference with 
conduction, very violent sensory impressions would excite vigorous 
innervation, which would overcome the obstruction and the otherwise 
impossible movement would be performed. 

A further proof of the mainly peripheral character of hysterical 
paralyses and ansesthesias is the fact that the voluntary as well as the 
involuntary movements are paralyzed, and that peripheral stimuli 
do not excite involuntary motor reflexes. 



DISEASES OP THE NERVOUS SYSTEM. 223 

The hysterical paralyses resemble central paralyses from the fact 
that the interference with conduction takes place very close to the 
exit of the nerves from the central organ, where the nerve bundles 
are still arranged in the same way as in the central organ itself. The 
distribution of the nerve fibres to the individual branches of the nerve 
and the muscles takes place peripherally. Hence, as in true central 
paralyses, it is rare to find single muscles paral3^zed in hysteria. 
Usually a group of muscles or an entire limb is paralyzed. 

The cortical nature of hysterical disorders is disproven by the 
fact that in general convulsions (hystero-epilepsy) consciousness is 
not abolished, as a rule, as it is in true epilepsy. 

Such a case, for example, as that reported by Kiepert (unilateral 
loss of sight and hearing, m^'osis and dilatation of the retinal veins 
on the same side) is explained very readily by dilatation of the small 
vessels on that side. I know of no lesion in any part of the brain 
which could produce such a combination of symptoms. 

Without denying the occurrence of central disorders in hysteria, 
I believe that the majority of symptoms are better explained by an 
injurious influence acting upon the peripheral nerves. Who knows 
how many cases of ovarian tenderness are really due to tenderness 
of the sacral nerves? It is well known that "ovarian pain" occurs 
even in men. So long as hysteria was regarded as occurring almost 
exclusivel}^ in females, it was plausible to connect it with the uterus. 
But now that it has been observed so often in males, and since it has 
been recognized that it may develop suddenly (traumatic hysteria) 
from violent emotional excitement, the old term should be abandoned. 
On account of its brevity, however, the word hysteria will hardly be 
replaced by a more suitable one, for example by vasomotor neuropa- 
resis multiplex variabilis, which best corresponds with the real con- 
dition. In time anatomical changes will probably be found more 
frequently in purely hysterical symptoms, especially if they have 
lasted for a long time. These changes should be looked for, not in 
the central organs, but in the peripheral nerves, especially at their 
passage through narrow canals. 

I have realty dilated upon hysteria to a greater extent than ac- 
cords with my purpose in this work. But I desired to show that the 



224 THE EYE IN RELATION TO DISEASE. 

logical consideration of a single symptom — here the hysterical disor- 
der of vision — may lead to the most important deductions concerning 
the nature of a hitherto obscure disease. In hysteria, accordingly, 
we have to deal with abnormal processes of innervation in the sym- 
pathetic, on the one hand with insufficient unconscious action upon 
the latter by the central organs, associated with voluntary motor im- 
pulses (page 120), on the other hand with exaggerated vasomotor re- 
ilexes. The fact that hysterical individuals lose less blood, when 
cupped, than others, I explain by increased vascular reflexes after 
cutaneous irritation, and not, as does Gilles de la Tourette, by per- 
manent vascular spasm. 

Traumatic Neurosis. 

So-called traumatic neurosis is regarded by some as a special form 
of disease, but its separate existence is denied by others. Its symp- 
toms consist of the mechanical results of the injury (for example, 
paralyses of the ocular muscles in fractures of the base of the skull, 
unilateral and bilateral disturbances of vision and blindness with 
subsequent atrophy of the optic nerve in fissures through the optic 
foramen, etc.) and of symptoms which are regarded as characteristic 
of hysteria or neurasthenia. Many observers, accordingly, speak of 
traumatic hysteria, neurasthenia, etc., and this really corresponds 
better to the actual conditions. The French writers also deny the 
existence of a special traumatic "neurosis." 

Among the symptoms frequently mentioned are : general tremor, 
even when the patient is not watched, intensified action of the heart, 
insomnia, increase and inequality of the tendon reflexes, muscular 
wasting, twitching of muscular fibres, vasomotor disturbances of all 
kinds, etc. Leaving out gross changes and solutions of continuity, 
these symptoms undoubtedly result, in part, from material changes 
in the spinal cord (capillary hemorrhages, corkscrew-shaped, i.e., 
torn axis cylinders, etc.). The symptoms either terminate in 
recovery or in progressive atrophic processes (so-called railway 
spine) . 

According to Oppenheim ("Die traumatischen ISTeurosen," Ber- 
lin, 1889), unilateral and bilateral concentric narrowing of the field 



DISEASES OF THE NERVOUS SYSTEM. 225 

of vision with Dormal ophthalmoscopic appearances is the most im- 
portant symptom, and this is confirmed by Benedict, Moebius, and 
Jolly. Schultze, Hitzig, and Rumpf oppose these views, and Mendel 
remains sceptical. Although the concentric narrowing of the field 
of vision is simulated more or less frequently, the investigations of 
Wilbrand, Uhthoff, Nieden, and others prove that it does occur after 
traumatism (^'^de Bruns, SchmidVs Jahrb., 1891, p. 81; Neurol. 
Centr.^ 1892, p. 118). According to Bernhard (Deutsch. med. 
Woch., 1888, ISTo. 13), concentric narrowing of the field may even be 
the sole symptom of a traumatic neurosis, but this is denied byotbers. 
In one case Fischer {Arch. f. Aug., XXIY, 2, p. 171) found exag- 
gerated reaction of the pupil to light (dilator paralysis?) together 
with pronounced concentric narrowing of the field of vision. [An 
instance of this kind was under my notice for about six weeks. The 
fields were about 20° in diameter and the optic nerves excessively 
hypersemic . — E D . ] 

In the majority of cases it is evident that the traumatism causes 
an outbreak of hysteria in a predisposed individual. The main vis- 
ual symptoms of this traumatic hysteria are concentric narrowing of 
the field of vision, blepharospasm (especially in injuries near the eye) 
and, in addition, disorders of the cutaneous sensibility. 

The trauma need not be very severe or act upon the entire body. 
For example, Lasegue {Jahr. f. Aug., 1878, p. 254) reports the case 
of a girl, aged fourteen years, in whom the outbreak of hysteria oc- 
curred after a handful of sand had been thrown against her right eye. 
It began with a blepharospasm which lasted four months, and was 
followed by other symptoms. 

Indeed, a violent fright is sufficient to produce the disease. Falk- 
enstein {Deutsch. med. Woch., 1891, p. 1096) reports the case of a 
boy of thirteen years in whom unilateral amblyopia and concentric 
narrowing of the field of vision developed after great fright at being 
threatened with a bloody knife. 

It is not justifiable to diagnose traumatic hysteria after an injury 
from mere concentric narrowing of the field of vision. Neither does 
it follow that total blindness will always result from the frequent fis- 
sures through the optic foramen. A slight hemorrhage at this spot 
. 15 



226 THE EYE IN RELATION TO DISEASE. 

may compress the optic nerve temporarily and later may be com- 
pletely absorbed. 

In addition, we must always remember that the symptoms which 
are regarded as characteristic of traumatic neurosis may be occa- 
sioned by other causes (for example, muscular tremor and accelerated 
action of the heart by drinking strong black coffee, smoking strong 
cigars, etc.). Rumpf's symptom, viz., acceleration of the pulse on 
pressure upon painful spots, can only decide the question when pains 
are really present or are simulated. 

Hypnosis and Sleep, 

All the symptoms of hysteria may be produced by suggestion, 
and intentional hypnosis may produce hysterical attacks. These 
circumstances render a relationship between these conditions proba- 
ble, although they are entirely distinct. 

Careful observation of the eye symptoms also throws a certain 
amount of light upon the hypnotic state. 

Heidenhain mentions spasm of accommodation (especially on fix- 
ing shining objects) as the first sign of beginning hypnosis ; after a 
while the pupil dilates but reacts vigorously to light. Foerster 
found the fundus normal at this stage. According to Luys and Bac- 
chi, redness of the papilla and increased fulness of the retinal vessels 
(vasomotor sympathetic paresis) are present in later stages. 

Opinions differ in regard to the conditions of the pupil in more 
advanced stages, for example, in catalepsy. According to Tambu- 
rini and Sepilli the pupil is constantly dilated and does not react to 
light; according to Fere it dilates and contracts during cataleptic 
sleep, according as the individual is directed to look at distant or 
near objects. In " waxen flexibility" Rumpf found wide separation 
of the lids, mydriasis and moderate exophthalmus, i.e., irritation of 
the sympathetic. During catalepsy Struebing found the eyes rotated 
upward, the pupils dilated and sluggish, etc. 

It is an interesting fact that Berger obtained dilatation of the pupil 
after strong sensory irritation even in the most profound hypnotic 
sleep. Hence the sensory-sympathetic reflex arc {vide p. 120) is not 



DISEASES OF THE NERVOUS SYSTEM. 227 

disturbed, and conduction outside of the cranium and spinal canal is 
intact. 

Among the frequently observed hyperse.sthesias is increased vis- 
ual power. 

Among suggested symptoms the most interesting one to us is 
blindness. The pupils are then moderately dilated and the reaction 
to light is almost abolished. Blindness with abolition of the reaction 
of the pupil to light is undoubtedly a peripheral symptom. The cau- 
sal condition must be located on the peripheral side of the chiasm. 
We are at once reminded of the optic foramen, and are inclined to 
place the visual disturbance, as regards its mode of development, 
parallel to that which occurs spontaneously in hysteria. 

In every spontaneous activity of the will there is also an uncon- 
scious cerebral action upon the vessels of the nerves of the limb or 
organ employed, and this evidently has a tonic vaso-constrictor effect. 
When the function of an entire cerebral hemisphere is excluded the 
signs of sympathetic paresis are also present. Function of the hem- 
isphere accordingly exerts a tonic action on the sympathetic. If one 
organ of special sense is chiefly employed in conscious acts, the tonic 
action of the brain is exerted chiefly on this organ, and the reverse 
is true of the other organs of special sense, whose impressions are 
neglected. For example, if the eyes are mainly employed in atten- 
tive reading or writing, a tonic action is exerted upon the vessels of 
the optic nerve (probably also upon those of the eye as a whole) , while 
the opposite condition obtains, for example, with regard to the ves- 
sels of the auditory nerve. If the latter dilate in the bony canal, 
conduction in the acoustic nerve will be interfered with to a greater 
or less extent by the more or less complete displacement of the medul- 
lary substance. The auditory impressions reach the central organ 
in a much less intense degree and are consequently perceived by the 
brain much less distinctly. As a matter of course conduction is not 
entirely interrupted. As soon as attention is again paid to auditory 
impressions, the tonic influence of the brain upon the vessels of the 
acoustic nerve again comes into play, and perhaps less intense vis- 
ual impressions may be neglected. 

The phenomena produced by suggestion in hypnosis develop spon- 



228 THE EYE IN RELATION TO DISEASE. 

taneously in hysteria. In the latter there is evidently an entire or 
partial loss of the influence of the central organs on the sympathetic, 
which constricts the vessels, and of the vascular reflexes after sensory 
stimuli. For this reason hysterical individuals, despite the similar- 
ity of the phenomena, are not especially well adapted for suggestion, 
although easily put into a condition of purely passive hypnosis pass- 
ing into catalepsy and somnambulism (grande hysterie, Charcot) . 

The color-blindness of hypnosis corresponds in the main to the 
color disturbances observed in hysteria. 

If, for example, any one is hypnotized by attentive fixation of an 
object, the attention is concentrated upon the organ of vision ; the 
other impressions of special sense are entirely neglected and finally 
hardly enter consciousness. I assume that now, in addition to the 
functional activity of the entire visual apparatus, a certain degree of 
vascular contraction develops in the latter while the opposite condi- 
tion obtains in the other sense organs. As a result of this, interfer- 
ence with conduction is produced at the places where the sensory 
nerves pass through unyielding bony canals, by the displacement of 
the medullary substance. Finally, the sensory impressions are no 
longer conveyed to the central organ. If the eyes are now closed, 
the brain no longer receives any impressions, and sleep occurs in the 
same way that a completely anaesthetic individual, who is also deaf, 
falls asleep when the eyes are closed (Struempell) . 

This leads us to consider the question of the nature of ordinary 
sleep. The theories that it is due to exhaustion, to the accumulation 
of products of disassimilation, to the necessity of a stage of rest dur- 
ing which new energies are gathered, are no longer tenable. Mauth- 
ner believes that sleep results from interference with conduction in 
the central gray matter, so that the cortex is separated centripetally 
and centrifugally from the periphery. He bases his theory mainly 
on the fact that sleep begins with ptosis, which he regards as a nu- 
clear paralysis of the levator. In fact, there is more or less complete 
interference during sleep with conduction between the cerebral cor- 
tex and the periphery, but, as in hypnosis, this may take place in the 
peripheral nerves. 

While falling asleep we first notice subjectively that the pulse is 



DISEASES OF THE NERVOUS SYSTEM. 229 

much fuller; this is especially noticeable in the vessels of the head 
on account of the more or less horizontal position. In sensitive indi- 
viduals the pulsation of the carotids in the petrous portion of the 
temporal bone may be so annoying that it even interferes with fall- 
ing asleep. There seems to be a general relaxation in the tonus of 
the sympathetic fibres to the vessels. The drooping of the lids, 
which Mauthner interprets as a nuclear paralysis of the levators, is 
an evidence of the insufficient action of the sympathetic, as is also 
proven by the coincident contraction of the pupils (sympathetic ptosis 
and myosis). Pilcz {Wien. med. Wocli., 1891, p. 835) also calls at- 
tention to the latter phenomenon. On simply closing the lids the 
pupils dilate, but in sleep they are contracted. 

The general dilatation of the vessels can only exercise an effect in 
closed spaces from which something can be displaced. This will be 
mainly noticed, in nerves which pass through canals, as circum- 
scribed displacement of the medullary substance. This will be 
the more marked, the finer the fibres, i.e., in the sensory nerves 
and nerves of special sense which possess finer fibres than the motor 
nerves. Hence stimuli which affect the peripheral sense organs will 
first be conveyed feebly to the brain, finall}" not at all, and hence no 
motor impulse will result. This is not disproved by the fact that 
certain motor functions, for example, respiration, continue during 
sleep. Inspiration is not due to peripheral stimuli but to the irrita- 
tion of the excess of carbonic acid in the blood of the medulla oblon- 
gata, and this is naturally the same in the sleeping and waking con- 
dition. 

Awaking occurs either spontaneously or as the result of a vigorous 
peripheral stimulus (sensory impression from the outside, fulness of 
the bladder, etc.) which is able to overcome the resistance to conduc- 
tion, and is converted in the brain into a motor impulse. This causes 
a contraction of the vessels, by means of which the conduction in the 
nerves is again restored. The opening of the eyes w^hich occurs on 
awaking must be regarded as the result of the action of the sympa- 
thetic. 

Hence, sleep will be mainly prevented, on the one hand, by exter- 
nal irritants, pain, etc. , which are continuously conveyed to the brain 



230 THE EYE IN RELATION TO DISEASE. 

and do not allow general dilatation of the vessels to occur, and on 
the other hand by irritative conditions in the cortex, as, for example, 
at the onset of so many forms of insanity which induce constant in- 
nervation impulses and thus cause contraction of the vessels. An 
obstacle may also be furnished by rigidity of the walls of the vessels, 
because the effect of the increased blood pressure is notably weakened 
by the impaired distensibility of the vessel. This probably occurs 
quite often in old age. 

Hypnotic sleep differs from ordinary sleep by the existence of the 
possibility of "suggestion," i.e., centripetal conduction is evidently 
not diminished as much as in natural sleep. Sensory impressions 
are still conveyed to the cortex, but are so enfeebled that they are re- 
garded not as impressions from the external world but as developing 
in the brain itself. The speech of the operator is mistaken for the 
individual's own "inward" speech, and is treated as if the thought 
were a spontaneous one. The fact that any one who has made up 
his mind to rise at four o'clock in the morning, and awakes at this 
time without any outside assistance, is as astonishing as if he does 
the same thing because it was suggested during hypnosis. This is 
also true of one who resolves to perform a certain action after a defi- 
nite interval, and does so at the proper time. It is well known that 
such actions may also be suggested (post-hypnotic effects) . 

These brief hints do not explain the whole of hypnotism. But it 
is important to note again that careful study of an eye symptom may 
be decisive as regards the interpretation of hitherto mysterious con- 
ditions. I will make one more suggestion. Attention has already 
been called to the fact that the nerves of sensation and special sense 
contain finer fibres than the motor nerves. Hence, in equal dilata- 
tion of the vessels, the centripetal paths will be more interfered with 
than the centrifugal tracts. The motor impulses from the cortex 
may therefore still be manifested in an approximately normal man- 
ner, while the sensory impressions from the outer world are conveyed 
to the cortex in a very imperfect manner or not at all. Hence they 
will have little or no effect upon actions except upon those to which 
the attention has been directed. Such are the words of the operator. 
On account of the interference with conduction they are very much 



DISEASES OF THE NERVOUS SYSTEM. 231 

weakened on reaching consciousness and are then treated as if they 
had developed in the individual's own brain. Under such assump- 
tions the explanation of the phenomena of suggestion offers no diflS- 
culties, and the explanation of somnambulistic conditions is also 
made easier. 

Neurasthenia. 

In addition to a few other symptoms such as, for example, fibril- 
lary tremor of the muscles, eye symptoms are among the most im- 
portant objective signs of neurasthenia. In a large number of cases 
we find the often-mentioned bilateral concentric narrowing of the 
field of vision with or without color disturbance and with or without 
impairment of central vision. At the same time there is rapid ex- 
haustion of the visual apparatus, swimming before the ej'es, some- 
times cloudy vision, — symptoms which are due in part to the rapid 
exhaustion of the nervous visual apparatus (ansesthesia retinae asso- 
ciated with hypersesthesia) , in part to weakness of the muscle of ac- 
commodation and of the internal recti during convergence (astheno- 
pia accommodativa and muscularis). According to some writers 
(Schweigger, Foerster, Wilbrand) there are frequent changes in the 
size of the field of vision, or the latter narrows in a spiral direction 
during the examination, in accordance with the increasing exhaus- 
tion. 

The pupils are said to be often dilated although the reaction to 
light is intact or even exaggerated. The size of the pupils is also 
said to change frequently, independentlj^ of the entrance of light, of 
convergence or accommodation. According to Loewenfeld, Pelizseus, 
Beard and others, the pupils vary in size although no organic disease 
is present. This symptom is usually a temporary one ; the pupil of 
one eye may always be larger or both pupils may alternate in this re- 
gard. But if the inequality of the pupils is constant and lasts a long 
time, a serious disease of the brain, particularly general paresis, is 
usually impending. We should then inquire whether paralysis of an 
ocular muscle has not been noticed, or whether the patient has not 
suffered from some disease in which such symptoms are common (al- 
buminuria, S3'philis, etc.). 



232 THE EYE IN RELATION TO DISEASE. 

A frequent symptom is inability to close the lids entirely, when 
standing with the legs together (Romberg's experiment) . Although 
the lids cannot be closed completely, fibrillary twitchings appear very 
quickly in the orbicularis. According to Loewenf eld {Muench. med. 
Woch., 1891, No. 50) this also occurs on standing with the legs sep- 
arated and even in the sitting position. Apart from weakness of the 
orbicularis this symptom is evidently due to spasm of the sympa- 
thetic. Voluntary motor innervation is enfeebled, the sympathetic 
reflexes are increased. The former corresponds to the weakness, the 
latter to the irritability; both together to "irritable weakness." 

The pulsation of the retinal arteries, \\'hich was seen occasionally 
by Raehlmann, is also probably due to the influence of the sympa- 
thetic. 

From these remarks it is evident that the diagnosis between neu- 
rasthenia and mild grades of hysteria may be diflicult. According 
to Loewenf eld concentric narrowing of the field of vision and circum- 
scribed anaesthetic patches of skin, which are so frequent in trauma- 
tic hysteria, are not observed in typical traumatic neurasthenia. Due 
weight must also be attached to the absence of hysterogenous points 
in pure neurasthenia. 

Like all other neurasthenic phenomena the eye symptoms are due 
either to general weakness and rapid exhaustion of muscular inner- 
vation (orbicularis, internal recti, ciliary muscle) or to increased 
sympathetic reflexes (contraction with or without subsequent relaxa- 
tion) . The latter cause probably explains the imperfect closure of 
the lids, the pupillary symptoms, and probably the disturbance of 
vision. The coincident occurrence of both kinds of symptoms, the 
irritable weakness, is the characteristic feature. 

Perhaps the sympathetic sj^mptoms also include the conjunctival 
hypersemia and dry catarrh, which is often present. Its character- 
istic features are : heaviness and impaired mobility of the lids, sensa- 
tion as if sand or some foreign body were lodged beneath the lids, a 
feeling as if the lids were lightly glued together. This condition is 
such a frequent one, however, that it cannot be utilized in making a 
diagnosis. 



DISEASES OF THE NERVOUS SYSTEM. 233 

Hypochondria. 

Like other parts of the body the eye may also be the source of 
complaints in hypochondria, although, in my experience, this does 
not happen very often. Hypersemia of the conjunctiva, beginning 
presbyopia and cataract are probably the most frequent tangible 
causes. Muscse volitantes and, much more rarely, vitreous opacities 
visible with the ophthalmoscope, may give rise to the fear of threat- 
ening blindness. 

Thorough examination of the eye is imperative in every case, es- 
pecially in view of the fact that the complaints concerning eye symp- 
toms usually have some material though often trifling substratum. 
Even in those individual whose complaints have been declared un- 
founded by other physicians, I would recommend careful examination 
of the periphery of the fundus with feeble illumination and in the 
erect image. 

Epilepsy. 

Very many ophthalmoscopic examinations have been made in epi- 
leptics. At the beginning of the disease, and when the attacks are 
rare, the appearances are normal, but during its further course ve- 
nous hyperaemia develops in the fundus, particularly in the retina. 
It is an interesting fact that Aldridge found the hyperaemia diminish 
under the use of potassium bromide and iodide, and again increase 
after their discontinuance. Koestl and Niemetschek regard the 
venous pulse as a constant symptom of epileps}^ but this is so fre- 
quent in healthy individuals that no weight can be attached to it. 
Those who have examined large numbers of epileptics also mention 
other ophthalmoscopic findings, such as neuritis, neuro-retinitis and 
atrophy of the optic nerve. But these conditions are complications 
which stand in no relation to pure epilepsy. 

The results of ophthalmoscopic examinations during the attacks 
are more interesting. Immediately before an attack, while the 
patient was complaining of dazzling, Horstmann (Jahr. /. Aug.^ 
1874, p. 427) found considerable hyperaemia of the papilla and dila- 
tation of the retinal veins. Raehlmann (Ber. d. Heidelberg ophth. 



234 THE EYE IN RELATION TO DISEASE. 

Ges., 1887) noticed vigorous pulsation of all the venous trunks on 
the papilla immediately before the attacks. The latter could be fore- 
told by the ophthalmoscopic examination. 

During the attack Koestl and Niemetschek found in one case 
slight dilatation of the arteries and contraction of the veins. AUbutt 
found hypersemia of the fundus three times and anaemia three times 
during and soon after the seizure. 

During the convulsions, in one case, Aldridge found the papilla 
markedly injected and the arteries dilated; immediately afterward 
there was striking pallor and narrowing of the arteries. The nor- 
mal condition was restored with returning consciousness. 

Horner {Jahrh. /. Aug., 1874, p. 426) found enormous venous 
congestion during the height of the convulsive stage. Bovel (ibid., 
1877, p. 229) found the papillae very hypersemic, not infrequently to 
an unequal extent, during and after the attacks. 

In three cases Tebaldi noticed striking contraction of the vessels 
immediately after the attacks. 

During the status epilepticus, immediately before the beginning 
of the seizure, I found (Ber. d. Heidelberg, ophth. Ges., 1877) that 
the arteries were narrow and regained the normal calibre when the 
attack ceased. In addition, the size of the ophthalmoscopic image 
varied by fits and starts (spasms of accommodation) . 

In a similar case Leber (ibid. ) found the fundus entirely normal. 

The condition of the retinal vessels varies, accordingly, during 
the seizures. They either show no change, or their condition is the 
same as that which must be assumed to exist in the cerebral vessels 
(arterial spasm), or the opposite condition obtains, viz., hypersemi i 
during the attack, which slowly subsides and must be regarded as 
collateral. The latter condition is the mostxommon one. 

The hemorrhages into the lids and beneath the conjunctiva, which 
develop not infrequently during an epileptic convulsion, may some- 
times be an important proof of the actual occurrence of a convulsion. 

The eye may also be affected in other ways. A visual aura may 
appear prior to the beginning of the attack. This may consist of an 
elementary subjective impression of light, such as seeing colors or 
flames, or it may form a complicated hallucination. According to 



DISEASES OF THE NERVOUS SYSTEM. 235 

Hughlings Jackson all colors may appear, from red to violet. Hil- 
bert {Arch. f. Aug., XV, p. 419) reports intense yellow vision lasting 
twenty-four hours before the convulsion. The visual hallucinations 
which appear as aurse may be repeated regularly in the same man- 
ner. For example, I observed a young man who, prior to each at- 
tack, saw French soldiers who always appeared in the same direc- 
tion. While on sentry duty during the war he suddenly found him- 
self in the immediate vicinity of a detachment of French soldiers and 
was compelled to beat a hasty retreat. After his safety was assured 
he had the first attack, and since then they have always been preceded 
by the aura described above. 

Spasms of the ocular muscles in the form of associated movements 
of both eyes, rolling movements and conjugate deviation are frequent 
symptoms of an epileptic attack. I have been able to demonstrate 
with the ophthalmoscope clonic spasms of accommodation during a 
convulsion. During the clonic stage Beevor saw rotation of the head 
toward the right and conjugate deviation of the eyes to the left ; later 
the opposite condition was noted. Nystagmus and variations in the 
size of the pupils (hippus) are sometimes observed during and after 
the attack. Simple conjugate deviation of the head and eyes is so 
frequent that Witkowski {Arch. f. Psych, u. Nerv., IX, 3, p. 443) 
even regards it as a constant initial symptom of every epileptic attack. 

Rudimentary attacks may consist either of part symptoms of a 
real attack or of symptoms which constitute the aura of real attacks ; 
for example, blue vision with obscuration of sight (Hughlings Jack- 
son), double blindness (Heinemann, Christensen). I have seen uni- 
lateral concentric narrowing of the field of vision advancing to com- 
plete blindness and lasting several minutes (spasm of the central 
artery of the retina) , and unilateral micropsia (spasm of accommoda- 
tion) ; also peripheral ocular symptoms, alternating with convulsive 
attacks. Nieden {Jahr. f. Aug., 1888, p. 265) regarded sudden ob- 
scuration and concentric narrowing of the field in both eyes, with in- 
ability to move the eyes upward, as a rudimentary attack, because an 
epileptic convulsion had occurred a year before. Hughlings Jack- 
son applies the term " epileptiform amaurosis" to attacks of blindness 
lasting a few minutes. But as the patient suffered from optic neuri- 



236 THE EYE IN RELATION TO DISEASE, 

tis and later became entirely blind, no relations to epilepsy need be 
inferred. 

After the attack, occasionally prior to the attack, concentric nar- 
rowing of the field of vision is regularly present on both sides, often 
with impaired central vision and not infrequently with concentric 
narrowing of the color boundaries or color-blindness (Westphal, 
Thomsen, etc.). This anomaly gradually subsides. It is also found 
after almost all the epileptic equivalents. The symptom may become 
important in suspected simulation. It is more frequent than the 
symptom recommended for this purpose by Echeverria (Jahr. /. 
Aug., 1881, p. 301), viz., post-epileptic variations in the size of the 
pupil without visible cause. It is said that this symptom is also ob- 
served not infrequently in the intervals between the convulsions. 

The condition of the pupils during the attacks varies so greatly, 
even in the same attack, that no general rules can be formulated. 
The reaction to light may be intact or lost. 

In two cases of epilepsy Fere noticed infrequency of the winking 
movements (Stellwag's symptom) and retardation of the upper lid on 
looking downward (v. Graefe's symptom), although there were no 
other evidences of Basedow's disease. 

Siemerling (Charite-Annal. , XI, p. 389) calls attention to the 
frequent occurrence (twenty per cent) of congenital anomalies of the 
eye in epileptics. He includes astigmatism, pronounced hyperme- 
tropia and myopia, nystagmus, abnormal sinuosity of the vessels and 
poor definition of the borders of the papilla. It is questionable 
whether all these conditions are congenital. 

Lundy observed an epileptic attack immediately after a cataract 
operation. On the other hand d'Abundo claims to have cured epi- 
lepsy by correction of astigmatism, Elliot Colburn and Frothingham 
by suitable convex glasses, Stevens by the operation for squint, 
Pechdo, Fumagalli, and Galezowski by enucleation of an injured eye. 

All true epileptic symptoms are evidently due to spasmodic con- 
ditions in the domain of the sympathetic. 

In unilateral (Jacksonian or cortical) epilepsy, Mueller {Jdhr. f. 
Aug., 1891, p. 315) calls attention to the frequent occurrence of ocu- 
lo-pupillary sympathetic symptoms (ptosis, myosis, enophthalmus) in 



DISEASES OF THE NERVOUS SYSTEM. 237 

the eye of the same side.' In this affection we can often see very 
clearly that one part of the cortex is attacked after another. The 
symptoms observed on the part of the eye are also cortical, such as 
conjugate deviation, scintillating scotoma, homonymous hemianopsia 
or defects of the field of vision, etc. These sjTuptoms are easily dem- 
onstrated because consciousness is intact. 

The term one-sided epilepsy is preferable to cortical epilepsy be- 
cause, in the ordinary form of the disease, the principal symptoms 
(convulsions, loss of sensibility and consciousness, conjugate devia- 
tion, bilateral visual disorders, optical aura, visual hallucinations) 
are due to the implication of the cortex, although the causal arterial 
spasm is perhaps located at the base of the brain. 'Not has it been 
proven that the cause of cortical epilepsy is located in the cerebral 
cortex itself. The unilateral non-central eye symptoms all take place 
within the smooth muscular fibres of the eye and its vessels. 

In agoraphobia or "fear of places," which is undoubtedly epileptic 
in character, Nieden {Deutsch. med. Woch., 1891, No. 13) demon- 
strated considerable concentric narrowing of the field of vision for 
white and colors during the attack. The field was narrowed to a 
third of its normal dimensions in aU directions. Considerable im- 
provement occurred in a few months under the use of bromides. It 
is very possible that the nature of agoraphobia really consists of the 
paroxysmal, pronounced, bilateral narrowing of the field of vision 
of cortical origin, resulting from bilateral spasm of the corresponding 
arteries. In bilateral cortical hemianopsia from disease of the ves- 
sels a very small central field of vision is often left {vide p. 61). 
In agoraphobia which is due to temporary spasm, not to permanent 
destruction in the visual centres, the remaining part of the field of 
vision will be correspondingly greater. 

Migraine and Scintillating Scotoma. 

Migraine and scintillating scotoma are discussed immediately 
after epilepsy because the origin of both must be attributed to the 

^ It seems to me more probable that this should read : Enlargement of the 
palpebral fissure and pupil, and exophthalmus, i.e., spasm of the sympathetic, 
in the eye of the opposite side. 



238 THE EYE IN RELATION TO DISEASE. 

sympathetic system. Moreover, they exhibit undeniable relations to 
epilepsy. With a certain degree of justice we may regard migraine 
as a rudimentary epileptic attack, and scintillating scotoma as a ru- 
dimentary migraine, inasmuch as every possible transition between 
them is occasionally observed. 

In hemicrania or migraine there ^re very frequent attacks of uni- 
lateral, paroxysmal headache, which may last from a few hours to a 
day and may terminate in vomiting. Other symptoms on the part 
of the sympathetic are often seen, especially oculo-pupillary symp- 
toms. 

Apart from so-called myopathic migraine we distinguish, prima- 
ril}^ a paralytic and a spastic or tonic form ; the former exhibiting 
signs of paralysis, the latter signs of spasm of the sympathetic. In 
the paralj^tic form we find enophthalmus, ptosis and myosis (with 
retained but correspondingly diminished reaction of the pupil to light) , 
injection of the conjunctiva, epiphora, photophobia, etc. The fundus 
usually appears normal, although hypersemia of the retinal vessels has 
been found in this form. 

In spastic or tonic migraine the palpebral fissure and pupil are 
moderately enlarged, but the latter reacts to light. Distinct exoph- 
thalmus is absent or very rare. 

The presence of oculo-pupillary symptoms forms an important 
means of distinguishing migraine from sui^raorbital neuralgia. They 
are absent in the latter, but pressure upon the nerve causes pain. 
Injection of the conjunctiva, epiphora and photophobia may be pres- 
ent in both. Gerhardt claims to have seen retinal congestion and 
arterial pulsation in neuralgia. Herpes zoster is distinguished from 
both by the sensory disorders of the skin and later by the eruption. 

Among other symptoms occurring in migraine, especially the 
spastic form, Nicati and Eobiolis {Gaz. des Hop., 1884, No. 27) 
mention tinnitus aurium and subjective noises, sour smell, salty 
taste, formication, coldness and other parsesthesise, anaesthesia, mus- 
cular tremor and spasms, paralyses, loss of memory, insomnia, deli- 
rium passing into temporary insanity. In the large majority of 
cases such symptoms must be attributed to more or less diffuse nu- 
tritive disturbances in the cerebral cortex. Temporary aphasia, 



DISEASES OF THE NERVOUS SYSTEM. 239 

hemiplegia, conjugate deviation of the eyes and head (AUbutt, Berry), 
spasm of convergence, etc., are also observed occasionally. There 
are likewise cortical brain symptoms, although the spasm of conver- 
gence may be nuclear in origin. 

Scintillating scotoma (migraine ophthalmique of the French writ- 
ers) is a very frequent phenomenon in migraine. It is an homony- 
mous disturbance of vision, which begins with scintillations, either 
in the centre or at the periphery, and often advances to complete 
homonymous hemianopsia. The reactions of the pupil are retained 
and the ophthalmoscopic appearances are normal. The attack may 
last from a few minutes to a whole day, and is observed particularly 
in the spastic form of the disease. 

In a much larger number of cases, however, scintillating scotoma 
occurs independently as a rudimentary attack of migraine, often 
without any known cause, sometimes from fasting, etc. It may dis- 
appear in a few minutes or in an hour without further symptoms, or 
it may be attended with one-sided pressure or pain in the head. Then 
it usually lasts half a day and not infrequently terminates in vomit- 
ing. 

Pure scintillating scotoma is very frequent, especially in those 
who do much brain work, and the temporary disturbance of vision is 
absolutely innocuous. It may always appear on the same side or 
may change from one to the other. A notable disturbance occurs 
only in those very rare cases in which it develops on both sides at the 
same time, as happened to my former teacher. Professor Horner, on 
one occasion. In such cases, however, it may be easily recognized by 
the characteristic scintillations. [A surgeon of the United States 
army, set. thirty-foar, who frequently suffered from migraine of a 
severe type, was entirely relieved by cylindric glasses to correct com- 
pound myopic astigmatism and the accompanying asthenopia. — Ed.] 

Hardly any other explanation is possible than that of spasm of the 
arteries of one visual sphere, but the cause of such a condition is en- 
tirely obscure. 

With advancing j^ears migraine and scintillating scotoma become 
less frequent or disappear, probably on account of the diminished 
elasticity of the walls of the vessels. 



240 THE EYE IN RELATION TO DISEASE. 

So-called ophthalmoplegic migraine (Charcot) is known in Ger- 
many as relapsing or periodical paralysis of the ocular muscles (vide 
p. 70) . This disease is improperly included under the heading of 
migraine because, in the majority of cases, there are positive ana- 
tomical lesions, usually basilar neuritis and perineuritis. 

Chorea. 

This disease is one of the few in which anatomical lesions are 
present with comparative frequency. Nevertheless, there are great 
differences of opinion concerning its nature. According to Germain 
See and others it has a rheumatic basis; according to Joffroy it is a 
cerebro-spinal developmental disease and is unconnected with rheum- 
atism. According to Jackson it is due to capillary emboli in the 
region of the corpus striatum, and indeed emboli are found not infre- 
quently in this region . But they are also found in other parts of the 
brain, and even in the spinal cord. Kahler and Pick call attention to 
the fact that these capillary emboli and hemorrhages are always sit- 
uated in such a position that they may interfere with the pyramidal 
tracts. The frequent coincidence of heart disease and chorea is well 
known. 

Two forms of chorea are recognized : a, ordinary chorea of chil- 
dren, rare in adults, and &, the chronic progressive form in adults, 
which finally leads to severe mental disturbance. The latter also in- 
cludes the hereditary type (Huntingdon's chorea) . Chorea (post- 
hemiplegic hemichorea) may also occur after spots of softening in 
the brain and in the course of progressive cerebral processes. In 
Bernhardt's case (Arch. /. Psych, u. New., XII, p. 495) right hemi- 
plegia first developed, then hemichorea, hemiathetosis, aphasia, 
agraphia, left ptosis and sympathetic myosis (on the side of the cere- 
bral disease !) and right hemianopsia. 

Despite the fact that twitchings are almost always observed in 
the face, the ocular muscles are rarely affected. Lifting the eyebrows 
and rolling the eyes, which increase on excitement and cease during 
sleep, are the most frequent. Nystagmus is very rare and does not 
form part of chorea. Mendel (Arch. f. Psych, u. Nerv., XX, 2, p. 
602) describes two cases in children of twelve and thirteen years. 



DISEASES OF THE NERVOUS SYSTEM. 241 

They suffered from chorea, nystagmus and atrophy of the optic 
nerve. It is possible, however, that the symptoms were due to 
ataxia. 

Warner {Lancet^ 1883, I, p. 273) reports tw^o cases in which the 
ocular muscles were involved. Bernhardt {Neurol. CentralbL, 1891, 
p. 377) mentions, in his report on a case of chronic chorea, that both 
eyes deviated to the inside and could not be easily rotated to the out- 
side (spasm of convergence) . 

With the ophthalmoscope Arlidge found pallor of the papiUa, 
while Bouchut often noted pronounced hypersemia. The ophthal- 
moscopic appearances are usually normal. 

An important case is that of Swanz}- (Ophth. Hosp. Rep., VIII, 
p. 181) in which embolism of the central artery of the retina occurred 
at the same time with the chorea. In Sym's case {Jahr. f. Aug., 
1888, p. 569) sudden blindness of the right eye developed during cho- 
rea in a child set. seven years. Ten years later mitral stenosis and 
atrophy of the right optic nerve w^ere discovered. The blindness was 
probably due to embolism of the central arterj-. These two cases 
demonstrate the development of chorea by multiple emboli, although 
this is not the sole cause of the disease. 

Gould claims to have cured a case of chorea by suitable glasses. 
According to Stevens, chorea is intimately connected with errors of 
refraction, but this view is strongly opposed by Bull (Jahr. f. Aug., 
1877, p. 366). 

Athetosis. 

Chorea is allied to athetosis, in which there are usually unilat- 
eral, rarely bilateral, tonic twitchings, especially in the limbs. It 
generally forms a part of certain forms of spastic hemiplegia. 

Nothnagel mentions contraction of both superior recti in right- 
sided athetosis. Greidenberg (Petersb. med. Woch., 1882, No. 23) 
describes left-sided amblyopia and mydriasis in left-sided athetosis. 
Goldstein {Jahr. f. Aug., 1878, p. 252) reports permanent nystag- 
mus with apparent movement of objects in athetosis, and in another 
case of right hemi chorea, which terminated in hemiathetosis, there 

was right hemianopsia with ptosis and myosis. Gairdner {Lancet, 
16 



242 THE EYE IN RELATION TO DISEASE. 

June, 1877) observed a pale, slightly swollen papilla with normal 
vision; Bjoernstroem {Jahr. f. Aug., 1877, p. 228) found double am- 
aurosis as the result of neuro-retinitis which terminated in atrophy of 
the optic nerve. These findings in the eye, which are probably ac- 
cidental in great part, permit no conclusion in regard to the nature 
of athetosis. 

Tetanus. 

Traumatic tetanus produces no eye symptoms apart from the red- 
ness of the conjunctiva, prominence of the eyes, etc., which are due 
to the violent spasms. 

In so-called tetanus hydrophobicus, however, a characteristic 
symptom is facial paralysis, but the so-called ocular facial (frontalis 
and orbicularis palpebrarum) is not always involved. This form of 
the disease occurs only after injuries in the distribution of the cere- 
bral nerves. The facial paralysis is usually on the same side as the 
injury, or, if the latter is in the median line (bridge of the nose), it 
is usually bilateral. 

The eye may constitute the door of entrance of the infection. It 
is probably not a mere coincidence that the two cases which I found 
in literature (Schultze, Neurol. Centralbl., 1882, No. 6, and Ramiro- 
Guedes, Jahr. f. Aug., 1886, p. 565) were due to a blow with a whip. 
It is well known that tetanus also occurs in horses and with com- 
parative frequency in those who take care of horses. In Ramiro- 
Guedes' case recovery occurred. Schultze 's case terminated fatally, 
but meningitis did not develop despite the fact that neuritis optica 
ascendens had extended to the optic foramen. 

Robinson {Lancet, March 3d, 1883) observed blindness of three 
day^' duration during the treatment of tetanus with calabar bean. 

Tetany. 

In tetany there are peculiar clonic, usually symmetrical spasms 
of the voluntary muscles. In mild cases and at the beginning of the 
disease they are often painless. In more severe cases and in the fur- 
ther course of the disease they are attended with pains, paraesthesise, 
and often with other nervous symptoms. The spasms begin usually 



DISEASES OF THE NERVOUS SYSTEM. 243 

in the fingers, although twitchings in the distribution of the ocular 
facial occur occasionally at the very start. The ocular muscles proper 
are very rarely affected (Hoffmann, Deutsch. Arch. f. kl, Med., 
XXXIII, Cases 5 and 12). 

Apart from the spasms themselves the main symptoms of this 
disease are: the production of the spasms by compression of the 
large arteries (Trousseau's phenomenon), increased mechanical ex- 
citability of all the motor nerves, and the increased faradic and 
galvanic excitability of all the motor nerves, with the exception of 
the facial. 

Pupillary changes in tetany are not very rare, particularly spas- 
tic mydriasis (Kunn, Wien. kl. Woch., 1889, p. 231). Kunn ob- 
served mydriasis associated with neuro-retinitis and terminating in 
atrophy of the optic nerve. Kussmaul {Berl. kl. Woch., 1872, 37) 
observed slight retinitis at the height of an attack of tetany. Jaksch 
{Zeitschr. /. kl. Med., XVII, SuppL, p. 171) reports double choked 
disc, but the case was not a typical one. It was complicated by epi- 
leptic attacks and was evidently" due to an anatomical lesion in the 
brain. Bouchut {Gaz. des Hop., 1873, p. 202) found neuritis in 
one case and hypersemia of the optic nerve in another. 

Tetany may be an independent disease, occurring in small epi- 
demics which usually attack males of the working classes, especially 
shoemakers, between the ages of sixteen and eighteen years; it is usu- 
ally benign in character. It may also be a symptomatic affection in 
certain diseases of the brain and stomach, a sequela of infectious dis- 
eases (cholera, typhoid fever, varioloid), or it may follow poisoning 
with various substances (ergotin, chloroform) . The development of 
tetany after extirpation of goitre is also well known. The above- 
mentioned complications on the part of the eye were found almost 
exclusively in the second form, which is a much more serious disease 
than the first form. 

The scanty eye symptoms add nothing to our knowledge of the 
etiology of this peculiar disease, which is evidently a general symp- 
tom due to various causes (insufficient amount of water in the mus- 
cles and nerves? Kussmaul). 



244 THE EYE IN RELATION TO DISEASE. 

Thomsen^s Disease. 

This affection, which is often hereditary, is probably a peripheral 
disease of the muscles (partial hypertrophy and proliferation of the 
connective tissue) . The groups of muscles which are set in action 
pass into temporary, painless, spastic rigidity, which subsides after 
a few seconds. The mechanical excitability of the nerves is un- 
changed, that of the muscles is increased ; pains and sensory disturb- 
ances are wanting. 

All the muscles or only single groups may be affected, but a pref- 
erence is shown for the lower limbs. The muscles of the face and 
eyes are often involved. 

Raymond {Gaz. Med. de Paris, June 27th, 1891) published two 
interesting cases which furnish a good illustration of the occasional 
implication of the eyes in Thomsen's disease. In the first, the visual 
disturbances accompanied the muscular spasms of the body or fol- 
lowed them. Exophthalmus was simulated by blepharospasm extend- 
ing behind the equator of the eye. Another symptom was " Graefe's 
sign," i.e., on looking downward the upper lid did not follow the 
eye, so that the sclerotic became visible above the cornea. In addi- 
tion contractures developed in the external ocular muscles ; these kept 
the globe rigid and could be felt subjectively. They could be pro- 
duced by sudden noises. Temporary amblyopia passing into com- 
plete blindness appeared at the same time. All of these symptoms 
vf ere not constantly present. At a late stage hypertrophy of the recti 
interni, as well as of other muscles, developed in connection with 
insufficiency of their opponents. Spasms of accommodation did not 
take place. 

In the second case eye movements were normal. But when the 
lids were shut it required some seconds to open them, and a longer 
time if the closure had been forcible ; then the opening had to be done 
at successive efforts. Graefe's symptom took place. Movements 
made at command ended in contracture, especially upward ; the op- 
posite movement required some seconds. Spasm of accommodation 
could not be elicited. Pupils reacted normally but soon returned 
from contraction to relaxation. Occasionally there was diplopia. 



DISEASES OF THE NERVOUS SYSTEM. 245 

Vision, color sense, visual field, refraction and fundus were nor- 
mal. If the head were moved, temporary amblyopia or total blind- 
ness for some minutes would ensue. This would be sometimes 
attended by phosphenes, which Raymond ascribes to pressure of the 
extrinsic muscles on the globe or of the muscles of the neck upon 
the aorta. 

The unstriped muscles are not implicated in Thomsen's disease; 
very seldom and only perhaps by accident do vasomotor disturbances 
occur. Therefore Graefe's symptom is not to be attributed to lesion 
of the sympatheticus but to contraction of the levator palpebrse su- 
perioris. Spasms of the extrinsic eye muscles as well as of other 
muscles can be brought about by spontaneous movements or in obe- 
dience to commands of another. The intrinsic eye muscles, the non- 
striped, escape, t.e., sphincter pupillse and musculus ciliaris. In 
only one case (Engel) was a sluggish pupil noted. 

In myoclony (paramyoclonus multiplex), which some set apart 
from hysteria as a peculiar convulsive type, there are lightning-like 
irregular contractions on both sides of the body. Others regard the 
condition as a type of hysteria — and Unverricht ("Myoclony," Vi- 
enna, 1891) says that sometimes all other muscles except the ocular 
may be concerned. This circumstance is strongly in favor of a co- 
incidence with, or relationship to, hysteria in which the same symp- 
toms occur. 



OHAPTEE II. 
DISEASES OF THE SKIN. 

The relationship of skin diseases to affections of the eye is com- 
paratively simple. We have to deal either with direct extension 
from the skin to the eye and vice versa, or with a coincident or suc- 
cessive appearance. The identity of diseases of the skin with those 
of the lids is easily demonstrable. This is more difficult as regards 
affections of the conjunctiva and cornea. 

The external integument of the lids is distinguished from that of 
the remainder of the body by its great tenuity ; the very loose sub- 
cutaneous cellular tissue is prone to oedematous swelling and is abso- 
lutely free from adipose cells. Even in general obesity the lids 
remain free from fat and often exhibit a striking contrast to the re- 
mainder of the integument of the face. A similar condition is pre- 
sented only by the integument of the scrotum. 

The surface of the lid is covered with fine downy hairs. Into the 
so-called intermarginal portion of the lid empty the so-called Meibo- 
mian glands, large acinous glands which are partly imbedded in the 
palpebral cartilage (tarsus). In front of their openings stand the 
multiple rows of eyelashes, into whose follicles unusually large se- 
baceous glands empty their secretion. In addition the free surface 
of the lids possesses large sweat glands. 

All these glandular structures — the Meibomian, sebaceous, and 
sweat glands — take part in the corresponding diseases of the skin, 
and attention must again be drawn to the fact that these parts are 
larger than in other parts of the body. 

The course of diseases of the conjunctiva and cornea often differs 

greatly from that of analogous affections of the skin, especially in 

those diseases which are attended with an eruption of vesicles. Very 

rarely do we find true vesicles and only for a brief period. The soft 

and thin epithelium soon desquamates, and we usually find only its 

246 



DISEASES OF THE SKIN. 247 

loss or an ulcer which discloses its vesicular origin merely by its 
rounded shape. If this evidence is wanting, the diagnosis may be 
very diiBficult (pemphigus con junctivse) . The diseases observed dur- 
ing acute exanthemata will be discussed under the heading of infec- 
tious diseases ; hard and soft chancre will be considered, for the sake 
of convenience, under the head of syphilis. 

Extension by continuity from the integument of the lids and 
surrounding parts to the eye, or vice versa^ is found in cancroid and 
in lupus, whose various forms, such as lupus erythematodes, hyper- 
trophicus, exfoliativus, etc., occur in the face and upon the lids, 
where they may give rise to extensive destruction, ectropium, adhe- 
sion of the lids to the globe, secondary disease of the conjunctiva and 
cornea, and finally to destruction of the eye. Inasmuch as the in- 
tegument of the face is affected in a characteristic manner over a 
large area, there is no difficulty in diagnosis except in the rare cases 
in which lupus first appears upon the conjunctiva. 

We then notice very chronic ulcers with jagged edges, often 
filled with proliferating granulations, and whose neighborhood is 
more or less infiltrated ; the corresponding lymphatic glands are also 
swollen. On careful examination it is often possible to find at the 
periphery and base of the ulcers small, whitish-yellow infiltrations 
as large as the head of a pin or smaller, whose presence is character- 
istic and corresponds to the individual lupus nodules. 

As is well known, the opinion is steadily gaining ground that 
lupus is a tubercular affection, a local tuberculosis of the skin. As 
the resemblance to tubercular diseases was seen more readily in lupus 
of the mucous membranes, the cases under consideration were for- 
merly often, and are now constantly, described as tuberculosis of the 
conjunctiva. The demonstration of tubercle bacilli in the secretion 
or in the granulations of the base of the ulcer now assures the diag- 
nosis. It is to be noted that in a series of cases the lupus of the con- 
junctiva was the only tubercular affection, and it is also well known 
that lupus patients may attain an advanced age. 

The eyelids are the favorite site of lupus er^^thematodes. Its out- 
line is in the shape of a butterfly and leads gradually to considerable 
shrinking of the skin, perhaps to eversion of all the lids. 



248 THE EYE IN RELATION TO DISEASE. 

Erysipelas is observed very frequently about the eye, inasmuch 
as facial erysipelas in the majority of cases passes over one or both 
lids. The disease may also take its origin directly from slight 
wounds and excoriations of the lids, particularly at the inner angle, 
more rarely at the outer angle. Manifold variations in the appear- 
ance of erysipelas are presented, corresponding to the varying struc- 
ture of the skin and subcutaneous tissues. The oedema of the lids is 
usually very pronounced, so that the palpebral fissure cannot be 
opened spontaneously, and is opened artificially only with difficulty. 
With the exception of more or less injection and oedema of the con- 
junctiva the eye is usually normal; there is often catarrh of the con- 
junctiva, very rarely ulceration of the cornea. 

Erysipelas of the lids exhibits a marked tendency to appear in the 
bullous and vesicular form, even when this is not true of the re- 
mainder of the integument. Secondary abscesses of the lids occur 
not infrequently after the erysipelas has run its course, and more fre- 
quently than in other parts of the integument. They vary greatly in 
size, but they almost always heal without material injury to the 
eye. 

Acute dacryocystitis is sometimes observed when the erysipelas, 
as frequently happens, passes across the region of the lachrymal sac. 
I have recently seen a case of this kind in which previously not the 
slightest sign of an affection of the lachrymal sac had been present. 
In other cases we merely have to deal with an acute exacerbation of 
a chronic affection. 

In not a few cases the general practitioner mistakes an acute dacryocystitis 
for erysipelas. In the former the symptoms are concentrated upon the lachrymal 
region ; the elevated inflammatory wall at the edges and the migratory character 
are absent. It is also mistaken occasionally (though this is always avoidable) 
for herpes zoster, which stops abruptly at the median line and is characterized 
by parsesthesiae, neuralgic pains, typical herpes eruption and, later, by typical 
radiating cicatrices. 

Although the eye usually remains intact, Coursserant {Jahrb. f. 
Aug., 1876) has observed bullous keratitis (associated with albumi- 
nuria), and Cornwell {ibid., 1882, p. 380) has seen cyclitis in phleg- 
monous erysipelas. Orbital abscess is observed in rare cases. A 
more frequent finding is simple infiltration, perhaps a mere serous 



DISEASES OF THE SKIN. 249 

soaking of the orbital contents, whereby the eye is protruded to a 
greater or less degree. In such cases optic neuritis or ischsemia from 
pressure of the orbital infiltration is observed, which terminate in atro- 
phy and usually in complete blindness. More rarely a certain de- 
gree of vision remains, with narrowing of the field of vision, scoto- 
mata and color disturbances. Pagenstecher, Hutchinson, Schenkl, 
Parinaud, N'ettleship, Carl and others have described such cases. 
Paresis of the ocular muscles, for example, the levator palpebrse supe- 
rioris, or partial paralysis of the motor oculi, such as mydriasis 
(Pagenstecher), may also persist. 

Knapp {Arch. f. Ophtli., XIV, 3) noted thrombosis of the retinal 
vessels after erysipelas, probably as the result of the inflammatory 
infiltration in the orbit. Hutchinson {Jahrh. f. Aug., 1883, p. 299) 
observed an elephantiasis-like condition of the lids after facial ery- 
sipelas. It is to be remembered, however, that elephantiasis Arabum 
runs its course upon its favorite sites (the external genitalia and 
lower limbs) in erysipelatoid or true erysipelatous attacks. On the 
other hand, a more or less doughy or firm oedema not infrequently 
remains for a long time after erysipelas of the lids. This resolves 
very slowly, but in the end it almost always disappears without leav- 
ing a trace. 

Embolism of the central artery of the right eye, which was found 
by Emrys Jones (Brit. Med. Joiirn., 1884, 1, p. 312) in erysipelas of 
the left side of the face, was probably accidental, unless the condi- 
tions noted were due to compression of the optic nerve. Between 
them and embolism the resemblance is sometimes striking. 

Carre {Gaz. cVOphth., 1882, 5) found acute infiammation of the 
lachrymal gland in erysipelas of the upper lid, in a man of thirty- 
five years. It is probable that this combination occurs more fre- 
quently. 

Two cases of spontaneous recovery of uveal disease after erysipe- 
las are reported by Nieden {Central f. Aug., 1885, March); strik- 
ing improvement of a " trachoma" after erysipelas was observed by 
Cocci {Jahr. f. Aug., 1884, p. 429), and recovery of an iridochoroidi- 
tis by Walb {Central, f. Aug., 1877, June). 

If erysipelas is complicated with meningitis the latter, as a 



250 THE EYE IN RELATION TO DISEASE. 

matter of course, may give rise to corresponding ocular symptoms 
(page 150). 

Eczematous disease of the integument and eye is observed coinci- 
dently or successively with equal frequency, and in the latter event 
the external integument as well as the eye may be the starting-point. 

In severe eczema of the face, scalp and integument of the lids 
we often find the eye completely free or only slightly reddened ; in 
other cases there is simple catarrh of the conjunctiva (Horner's ecze- 
matous catarrh), which is evidently due to the entrance of irritating 
and decomposed secretion into the conjunctival sac, and which usu- 
ally disappears spontaneously with the recovery of the facial eczema. 
But almost purely purulent catarrhal affections of the conjunctiva 
may also occur, and these require independent treatment. 

In many cases an outbreak of eczema occurs at the same time 
upon the conjunctiva and the cornea. As we have already remarked, 
real vesicles are rarely seen. The earliest form which I have found 
showed merely a club-shaped projection of infiltrated epithelium, 
evidently the former covering of the already ruptured vesicle. This 
is rapidly desquamated, and we generally find at the start a rounded 
ulcer which has an injected, thickened and infiltrated base upon the 
conjunctiva, and is surrounded by a slightly infiltrated zone when 
situated on the cornea. 

In pure cases the more marked congestion of the vessels is con- 
fined to the immediate neighborhood of the ulcer. It is only when 
the latter is infected secondarily from the conjunctival or lachrymal 
sac, that extensive purulent processes occur. These progress in area 
and depth and, upon the cornea, are especially apt to bring danger 
to the eye (progressive ulcers with hypopyum, fascicular keratitis). 

The individual ulcers vary in size from that of a pin-point to 4 or 
5 mm. in diameter; the latter may deserve the term eczema impe- 
tiginodes. 

Eczema of the lids, conjunctiva and cornea hardly ever occurs in 
the new^-born, is very frequent during childhood, diminishes after 
the period of puberty, and is rare at an advanced age. It is then 
generallj^ observed during convalescence from severe, especially infec- 
tious diseases, or in general conditions of weakness, for example. 



DISEASES OF THE SKIN. 251 

during pregnancy or the puerperal condition. [Eczema of the face 
may occur in subjects of advanced age having a gouty diathesis, 
under an acute attack with severe conjunctivitis both palpebral and 
ocular. It may cause extreme distress both in pain and photophobia, 
and may be very obstinate. — Ed.] 

According to my notes, eczematous disease of the nasal mucous 
membrane is the starting-point in three-fourths of all cases of ec- 
zema of the eyes and face, or is present at the same time. This is 
much more common than primary eczema of the face. The eye itself 
may also be the starting-point. The overflowing conjunctival secre- 
tion macerates the integument of the lids and face, and typical ecze- 
matous eruptions make their appearance. Even in many cases of 
so-called atropine catarrh, the first thing is extensive erythema of the 
face and lids, which is converted into eczema at the end of a few 
days. 

The latter cases are evidently the result of the spread of an in- 
fectious process which produces the typical eruption after macera- 
tion and softening of the epidermis. In an entirely analogous man- 
ner we find not infrequently that eczema develops in little children 
upon the dorsal surface of the hands, if they press them for a long 
time against the spasmodically closed eyelids, on account of severe 
photophobia. On the other hand it is very doubtful whether the 
micro-organisms found by Burchardt, Gifford and others are the real 
cause of the disease. It is probable that they enter the ulcers second- 
arily from the conjunctival sac, inasmuch as inoculations proved 
futile. The demonstration is rendered very difficult by the fact that 
we are unable to examine the unruptured vesicles. We always find 
ulcers already contaminated by the numerous microbes of the con- 
junctival sac. It is also possible that several microbes possess the 
power of producing rounded vesicles and ulcers, while on the other 
hand it cannot be denied that the cause may reside in purely 
chemical injuries, for example, in the eczema due to the inges- 
tion of certain articles of food, and which develops like urticaria 
under similar conditions. It is an interesting fact that I have re- 
peatedly observed a typical eczema ab ingestis after the administra- 
tion of cod-liver oil. As this is a frequent remedy in eczematoua 



252 THE EYE IN RELATION TO DISEASE. 

affections, the observation is calculated to lead us to exercise caution 
in its use. 

One of the favorite sites of eczema squamosum of adults is the 
surface of the lids, where it is often sharply defined. 

The propriety of calling these diseases of the conjunctiva and cor- 
nea eczematous is undoubted when an evidently eczematous disease 
can be recognized. If, for example, with every acute exacerbation 
of a nasal eczema fresh eruptions appear upon the conjunctiva and 
cornea and then disappear with the subsidence of the primary dis- 
ease, it is difficult to regard the histologically analogous processes as 
not identical. Less decisive is the coincidence with so-called scrofu- 
lous symptoms in other places, and which will again be referred to 
in discussing scrofula. On account of the frequency of their co-ex- 
istence, Arlt applied the term scrofulous conjunctivitis to the affection 
of the conjunctiva in question. It is remarkable that he did not ap- 
ply this prefix to the analogous inflammation of the cornea, but used 
the term scrofulous keratitis for those forms which are known to 
others as interstitial or parenchymatous keratitis. Eczematous dis- 
ease of the conjunctiva and cornea is known most frequently under 
the indifferent term " phlyctenulse, " although vesicles proper are 
hardly ever seen. 

All diseases of the cornea and conjunctiva with roundish infil- 
trations leading to ulceration need not be regarded as eczema- 
tous. For example, very similar infiltrations and ulcerations, pass- 
ing into vascularized patches, occur in the pannus of follicular 
blennorrhoea (trachoma). At the head of a growing pterygium, for 
example, we very often find punctate and larger rounded infiltrations 
and ulcers, which are probably traumatic in character. In the ab- 
sence of eczema of the nose or skin, a single rounded ulcer of the 
conjunctiva surrounded by an injected zone, or a single analogous 
ulcer of the cornea, whose etiology is unknown, cannot be called 
eczema, although the possibility that such an assumption is correct 
cannot be excluded. Perhaps bacteriology may here prove success- 
ful, although the conditions in the conjunctival sac are very unfa- 
vorable to investigations. 

I would suggest that the term eczema be applied to those diseases 



DISEASES OF THE SKIN. 253 

of the conjunctiva and cornea which are associated with eczema in 
other parts of the body and whose prognosis and course depend upon 
the latter. When this is not the case, the neutral term " phlyctenulse" 
may be retained. 

Richey {Chicago Med. Journ. and Exam., April, 1888) claims 
to have seen two cases of eczema of the lids from " ciliary tension" in 
hypermetropia, and to have cured them by correcting the error of 
refraction. Although this is probably an extremely accidental coin- 
cidence, we may recall the fact that a connection between hyperme- 
tropia and seborrhoea of the lids and edges of the lids, and also re- 
covery of the latter by the use of proper convex glasses, has been 
several times maintained with great positiveness. 

Herpes zoster and vulgaris also occur upon the integument of the 
lids. The disease of the cornea which corresponds to herpes zoster 
(herpes zoster ophthalmicus) has long been known, and its course 
corresponds more or less to that of so-called neuro-paralytic keratitis 
(p. 207) . The herpetic ulcers are infected from the conjunctival sac, 
and this is followed by progressive destruction of the more or less 
insensitive cornea. This may heal at any stage, but not infrequently 
leads to destruction of the eye. 

Herpes vulgaris or febriJis of the cornea is much more common 
than herpes zoster. To Horner we owe the credit of its discovery. 
Groups of clear vesicles appear spontaneously or under conditions in 
which eruptions of herpes appear in other places, and not infrequently 
at the same time with the latter. After a certain length of time, 
perhaps a few hours, the epithelial covering ruptures, and this gives 
rise to very irregular, often branching, losses of substance. These 
show distinctly, however, that they are formed out of individual cir- 
cular erosions. At the same time the sensibility of the cornea is 
moderately diminished. 

The disease may pass rapidly, but its course is usually protracted, 
inasmuch as the base of the erosion becomes infiltrated by infection 
from the conjunctival sac. The disease often remains stationary for 
weeks, but finally heals with a very characteristic branching cicatrix. 
Progressive suppuration (ulcus serpens) gives rise, in rare cases, to 
loss of the eye. 



254 THE EYE IN RELATION TO DISEASE. 

In recent cases the disease can hardly escape recognition. At 
the most it can be mistaken for certain traumatic losses of substance, 
but this will be prevented by the previous history. In the later 
stages the characteristic appearance is often effaced, especially after, 
extensive infiltration and vascularization of the cornea. The opacity 
which is finally left hardly ever fails of recognition. 

Herpes vulgaris cornese has been described under various names, 
such as furrow keratitis (Makrocki), keratitis dendritica (Emmertj, 
keratitis ramiformis (Hansen- Grut), etc. 

It seems to me more or less doubtful whether the keratitis de- 
scribed by Stellwag {Wien. kl. Woch., 1889, No. 31), the keratitis 
maculosa of Reuss {ib., No. 34), the keratitis puncta superficialis of 
Fuchs {ib., No. 44), Adler's keratitis superficialis centralis (^6., No. 
37), etc., are identical with herpes, although they appear, at least, to 
be allied in character. 

Seborrhcea in its different forms is very often observed coinci- 
dently on the lids and the scalp (scaly form), or in the face and upon 
the nose (oily form, seborrhcBa fluida). In the face as well as upon 
the lids it often provokes an outbreak of acne. The acne vulgaris of 
the lid is usually known as hordeoleum, and is distinguished from 
acne of the face by the large size of the individual eruptions, corre- 
sponding to the much larger size of the glandular structures of the 
lids, the suppuration of whose periglandular connective tissue pro- 
duces the disease. It attacks chiefly the large sebaceous glands in 
the vicinity of the free border of the lids, but the sweat glands of 
their surface or, still more rarely, the Meibomian glands may be 
affected. 

As in facial acne, periods of eruption often alternate with free in- 
tervals; this also happens in styes. An outbreak may occur upon all 
four lids. Both affections take place very often at the same time, 
and particularly at the period of puberty. 

The acarus or demodex f olliculorum is found in both {vide Wecker, 
"Traite d'Ophth.," I, p. 78). 

When the affection of the lids is extensive, it gives rise to more 
violent pain, oedema of the lids and of the conjunctiva. These 
symptoms are especially striking when the stye is situated at the 



DISEASES OF THE SKIN. 255 

outer angle, on account of the disturbance of circulation and of the 
outflow of lymph. As in acne, the most effective treatment, apart 
from the individual eruptions, consists in the cure of the chronic 
seborrhoea whose secretion gives rise to the acne pustules by occlud- 
ing the excretory ducts of the glands. 

While the connection between hordeolum and acne vulgaris is 
evident at once, the relationship between chalazion and acne rosacea 
is less easily understood. They both appear at the same period of 
life, but are found with comparative infrequency at the same time. 
Their mutual relationship is decided rather by the histological condi- 
tions and the connection of both with outbreaks of acne vulgaris. 
Both may arise from ordinary acne pustules. Acute exacerbations 
are often seen, and are usually followed by the growth of little tu- 
mors. The anatomical substratum common to both is a granulation- 
like tissue, often containing giant, cells, and which, in view of the 
frequent recurrence of chalazion treated by operation (insufficiently!) 
may even lead to a suspicion of a relationship to sarcoma. The in- 
terpretation of chalazion as a local tuberculosis (Tangl), on account 
of the (no doubt accidental) discovery of tubercle bacilli, has been 
sufficiently disproven. 

Among the differential features between chalazion and acne ro- 
sacea may be mentioned : 

a. In chalazion the indvidual tumor is usually larger, correspond- 
ing to the notable size of the Meibomian glands, which are generally 
involved. The tumor consequently is situated firmly on the palpe- 
bral cartilage, which usually bounds its posterior surface. In acne 
rosacea, however, tumors are sometimes seen which do not yield 
in size to the largest chalazion. 

h. The contents of the chalazion is often a central drop of pus, a 
transition to acne vulgaris, whose nodules in later life not infre- 
quently "harden" into chalazia. A conversion into cysts is very 
rare in acne rosacea. 

c. The more frequent solitary development of chalazion, as com- 
pared with the multiple eruptions of acne rosacea, corresponds to the 
smaller number, but more considerable size, of the affected glandular 
structures in the former. But chalazion is quite often multiple; in- 



256 THE EYE IN RELATION TO DISEASE. 

deed very many are often present, and the individual nodules are 
sometimes evidently composed of several smaller ones. 

d. The mobility of the integument over the chalazion is explained 
by the fact that the affected glands are not situated in the cutis and 
the subcutaneous tissue, as in ordinary acne rosacea, but, at least at 
the start, within the palpebral cartilage. 

On the whole we are justified for the present in regarding chala- 
zion, despite the various possible objections, as the affection of the 
lids which corresponds to acne rosacea. The existing differences are 
readily explained by the different local conditions. Even acne rosa- 
cea of the nose often differs greatly from the similar affection of the 
remainder of the face. 

The effective treatment of both affections is also analogous, viz., 
careful removal of the individual granulation foci, because relapses 
are apt to occur from proliferation of remaining tissue after closure 
of the opening made by operation. Sulphur treatment, which is 
often very effective in acne of the face, cannot well be applied in that 
of the lids. But in several cases the treatment of coincident acne 
rosacea of the face with sulphur caused a striking subsidence of the 
previously existing and recurring acute exacerbations of chalazion. 
No influence upon the completely developed tumor was ever observed. 
But the occasional spontaneous disappearance of a long-existing 
chalazion is not a very rare event, although the disappearance is not 
often absolutely complete. 

[The parallel between acne vulgaris and hordeolum and between 
acne rosacea and chalazion was first drawn by Horner. The two lat- 
ter are not yet very generally held to be cognate.] 

The comparison with affections of the skin has also shed light 
upon so-called spring catarrh, an interesting disease of the conjunc- 
tiva, which has not long been recognized and whose relations were 
quite obscure. 

Saemisch, who first described this affection as a special disease 
in his handbook, laid the chief stress upon the most striking symp- 
tom, viz., the peculiar proliferations at the rim of the cornea. These 
had been occasionally seen and described before, for example, by 
Graefe as phlyctsena pallida, but this very term shows that it was 



DISEASES OF THE SKIN. 257 

falsely regarded as a variety of conjunctival eczema. Horner and 
his pupil Vetsch (Diss. Zurich, 1879) then called attention to the 
frequently independent but often coincident change in the conjunctiva 
palpebrarum and the fornix. 

The disease is not a catarrh. With the beginning of the warm 
season, generally among boys at the period of puberty, the signs of 
conjunctival hyperaemia make their appearance, viz., heaviness of 
the lids, a feeling of dryness and as if sand were in the eye, exhaus- 
tion, sensitiveness to smoke, dust and artificial illumination, a sen- 
sation "as if the eye were not properly lubricated," etc. There is no 
real secretion to agglutinate the lids on waking or accumulate in 
the angles of the eyes. Often we find merely a few shreds of mucus 
in the fornix of the conjunctiva. As a rule, also, there is no trace 
of follicles, although an accidental coincidence is not excluded. 

A characteristic sleepy appearance of the patient, resulting from 
slight drooping of the upper lid, generally strikes us even at a dis- 
tance. This feature alone often makes the diagnosis. The conjunc- 
tiva palpebrarum and the fornix show, in simple cases, merely a more 
or less pronounced milky opacity of the epithelium. This is not so 
marked or so diffuse as in croup of the conjunctiva and cannot be 
removed with the forceps. 

In the majority of cases these are the sole findings. In others we 
find, especially upon the inner surface of the upper lid, more or less 
numerous, flattened proliferations, pedunculated like a fungus, vary- 
ing in size up to that of a pea, and also covered with the cloudy epi- 
thelium. They are sometimes very numerous and, pressed closely 
together, may cover the entire surface of the lid. In about one-third 
of the cases the characteristic limbus proliferations develop around 
the cornea. They are generally most developed within the palpebral 
fissure. They are pale, yellowish-red, flat, granular thickenings of 
the conjunctiva, which may extend for 1 to 1^ mm. upon the cornea 
and occasionally surround the latter in its entire circumference. After 
many attacks, occasionally not until the lapse of ten years or more, 
everything disappears without a trace, or there is a slight limbus 
opacity of the cornea and slight drooping of the upper lid. Serious 

complications are entirely wanting. 
17 



258 THE EYE IN RELATION TO DISEASE. 

The affection occurs most frequently at the period of puberty; 
subsequently its frequency diminishes rapidly, and it is rarely ob- 
served after the age of thirty or forty years. 

The microscope shows, in all diseased parts, that the otherwise 
normal epithelium is strikingly thickened, even threefold and four- 
fold It often sends short rounded prolongations toward the conjunc- 
tival tissue. It is only in rare cases, and then only in larger limbus 
proliferations, that the prolongations are longer and more or less 
branched. The individual cells have the appearance of ordinary 
epithelium cells, perhaps a little larger and often very distinctly of 
the type of spinous (echinate) cells. At the border of the process 
these pass imperceptibly into the normal epithelium. At the surface 
of the epithelium there are often numerous cells in a condition of 
mucous metamorphosis, and these evidently furnish the material for 
the tough mucous threads, the sole secretion, in the fornix of the con- 
junctival sac. The conjunctival tissue beneath the epithelial thick- 
ening is absolutely normal in recent untreated cases. If it has been 
cauterized repeatedly, it is often richly infiltrated with cells, and then 
numerous round cells are found in the epithelium. 

The accidental observation of the coincidence of so-called spring 
catarrh with an eruption of miliary warts upon the entire integu- 
ment of the forehead led me to examine more closely into the analogy 
with warts, and, in fact, this analogy is complete if we accept the 
notion of warts of the mucous membrane. 

The period of development is the same, and the microscopical ap- 
pearances, the uselessness of all irritant treatment, the spontaneous 
and complete recovery after a longer or shorter period, etc., warrant 
us in interpreting spring catarrh as a warty formation upon the con- 
junctiva. The differences are sufficiently explained by the fact that 
the eruption occurs upon a mucous membrane. The wider diffusion 
is also explained by the circumstance that, as a result of the annoy- 
ance induced b}^ the rough surface of the conjunctiva during move- 
ments of the eye, the affection is subject to more frequent irritants 
by rubbing, irritating treatment, etc. , than in parts of the integument 
where it practically causes no disturbance of function. It is well 
known that warts are quite common upon the free margin of the lids. 



DISEASES OF THE SKIN. 259 

I also wish to call attention to the fact that 1 have known very 
pronounced cases, without the limbus proliferations, to be explained as 
" chronic blennorrhoea" by competent men only a few years ago, and 
which were treated as such. If the term " trachoma" is to be selected 
for a conjunctival affection, this surely applies to "spring catarrh," 
which causes disturbance only on account of the rough surface of the 
conjunctiva. The best appellation is conjunctival warts, verrucse, or 
verrucositas conjunctivse. 

As in the case of spring catarrh the coincident observation of a 
cutaneous eruption may serve to explain the condition, so the same 
relation holds good in that disease of the conjunctiva which is sup- 
posed to correspond to pemphigus. Here, likewise, a true vesicle is 
hardly ever observed, but merely the infiltrated loss of epithelium, the 
ulcer. This development of ulcers is very extensive and has given 
rise, in all observed cases, to adhesions between the lid and globe, 
with opacity and covering of the cornea, to total symblepharon, and 
thus to loss of sight. Treatment has been entirely useless, except 
that Samelsohn (Heidelberg Congress, 1879) claims to have cured 
two cases. The disease is very rare and was first described by White 
Cooper and Wecker as pemphigus of the conjunctiva, on account of 
coincident pemphigus of the integument. Without the latter a posi- 
tive diagnosis can hardly be made. Malcolm Morris {2Ion. f. pract. 
Derm., May loth, 1889) has collected twenty-eight cases of pemphigus 
conjunctivse. They affected all ages, from infancy to the age of 
seventy-six years. In eight cases the disease first attacked the eye. 
It is probable, however, that this category includes the majority 
of cases which have been described as spontaneous symblepharon 
posterius, i.e., spontaneous adhesion of the conjunctival sac. Pem- 
phigus of the integument may have been absent for a time or may 
have been overlooked. 

Tilly {JaJir. f. Aug., 1888, p. 288) saw pemphigus of the conjun- 
tiva develop at the age of five years, after vaccination ; it is usually 
observed at a later age. Inoculation of the contents of pemphigus 
vesicles upon the conjunctiva and buccal mucous membrane of ani- 
mals gave negative results (Bandler, Prag. med. Woch., 1890, p. 
528). 



260 THE EYE IN RELATION TO DISEASE. 

Despite the great difference in their appearance, the association 
of the disease of the skin and conjunctiva in pemphigus is univer- 
sally acknowledged. This is by no means true of the much more 
frequent eczema and the forms of acne. Spring catarrh is also re- 
garded generally as a disease sui generis. 

In elephantiasis Arabum the lids may also take part in the pro- 
cess, indeed it may even be confined to the lids. Hutchinson has 
stated {vide p. 249) that elephantiasis of the lids may follow erysipe- 
las, but the latter may be merely a symptom of the elephantiatic pro- 
cess, as is true of other parts of the body. 

In a case of elephantiasis of the left lower limb, Michel {Arch. f. 
Ophth., XIX, 3) found at the autopsy enormous thickening of the 
chiasm and right optic nerve, which was due to hyperplasia and scle- 
rosis of the connective tissue. It is very doubtful, however, whether 
there is any intimate connection between the two events ; at least, 
the relations are entirely obscure. 

Xanthelasma may also be mentioned here with some justification ; 
the microscopical findings (dilatation and thrombosis of the capillary 
lymph fissures and subsequent conversion into connective tissue) in- 
dicate a process which is similar to that of elephantiasis. The lids, 
in which xanthelasma usually begins, are in a position in which the 
domains of several small arteries border on one another, and hence 
they are in a comparatively unfavorable condition for nutrition and 
blood supply, and also as regards the lymph circulation. Hence, 
spontaneous gangrene of the lids, which, for example, I observed in 
one case after measles, occurs symmetrically in those parts in which 
the xanthelasma usually begins. However, nothing is known con- 
cerning the connection or coincidence of xanthelasma and true ele- 
phantiasis. 

Elephantiasis GrsBCorum or lepra will be considered under the 
heading of chronic infectious diseases. 

Ichthyosis and fibroma molluscum also occur upon the lids. In 
the former, apart from the ectropium due to shortening of the integ- 
ument of the lids, the eye itself may be implicated, usually in the 
same way as in pemphigus or " trachoma" (essential retraction) . 

Phthiriasis of the lids, body lice and their nits upon the eyelashes. 



DISEASES OF THE SKIN. 261 

which look as if strewn with black dust, sometimes enable us, even 
at a distance, to suspect the presence of these parasites also on other 
parts of the body. 

According to Goldenberg {Berl. kl. Woch., 1887), lice upon the 
scalp are said, in a series of cases, to have given rise to relapsing 
conjunctival catarrh and eczema of the margin of the lids, which re- 
covered spontaneously after removal of the lice. Herz {Mon. f. 
Aug., 1886, October) also claims to have observed that they produce 
"herpes cornese Stellwag," i.e., eczema, in a reflex manner. Both 
are undoubtedly of a traumatic, infectious character, resulting from 
rubbing the eyes with fingers which had been soiled by the excre- 
tions of the lice. 

Other diseases of the skin, which also occur occasionally on the 
lids, manifest no peculiarity. 

Mooren (" Hauteinfluesse und Gesichtsstoerungen," Wiesbaden, 
1884) states that during chronic cutaneous eruptions he has often 
seen the development of cataract. Rothmund {Arch. f. Oplith., 
XIV, 1) also observed the development of cataract in early childhood 
among the children of three families with a peculiar affection of the 
skin. Rothmund defines the disease as reticular fatty degeneration 
of the stratum Malpighii and of the papillse, with secondary atrophy 
of the latter and rarefaction of the epidermis. The skin disease be- 
gan at the third to sixth month of life, the cataract between the 
ages of three and six years. Of the fourteen children of the three 
families, living in three adjacent villages, seven suffered from the 
skin disease and five of these from cataract; the other two were 
still under two years of age. In a girl of twenty-two years, 
Meden {Centr. f. Aug., 1887, p. 353) observed the formation of a 
cataract in combination with telangiectatic dilatation of the capilla- 
ries of the entire integument of the face. He also emphasizes the 
relation between skin disease and development of cataract. 

Foerster observed general prurigo associated with albuminuric 
retinitis, but it is evident that the renal affection to which the patient 
finally succumbed was the cause of both conditions. 

Mooren {I. c.) found retinal hemorrhages in extensive cutaneous 
burns, and regards them as a reflex neurotic disturbance of circula- 



262 THE EYE IN RELATION TO DISEASE. 

tion. I observed two similar cases in the Zuerich Surgical Clinic, 
and Wagenmann {Arch. f. Ophth. , XXXIY , 2) has also published 
a case. We evidently have to deal with sepsis from absorption of 
products of decomposition or the destruction of red blood globules 
{vide Welti, in Ziegier and Nauwerck "Beitrage," IV, p. 251), 
i.e., with the retinal hemorrhages of septicaemia which are found 
so frequently when looked for. They are much more common in 
extensive burns than might be inferred from the few published 
cases. 

Mooren also reports visual disorders after suppression of perspira- 
tion of the feet, which were cured by inunctions with turpentine 
and spiritus formicarum which re-excited the "normal" secretion. 
Sudden drying of moist eczemas is said to have produced hypersemia 
of the retina and hypersesthesia of the optic nerve. In extensive 
eruptions on the scalp, and in favus, he claims to have repeatedly 
observed retinitis and optic neuritis. Rampoldi {Jahrb. f. Aug., 
1882, p. 334) also mentions various complications in favus: in one 
case bilateral iritis serosa, in two cases iridocyclitis, in one case iri- 
docyclitis with cataract, in one case senile cataract in a former favus 
patient. There is no doubt that these were chiefly accidental coin- 
cidences. 

Broemser {ib., 1870) saw a very vascular metastatic retinal sar- 
coma after ligature of a pigmented mole on the cheek, but without 
development of a tumor in the latter locality. Hence the connection 
between the two is doubtful. 

In a case of multiple skin tumors with the structure of fibroma 
lipomatodes, Hirschberg {Arch. f. Aug. u. Ohr., TV, 1) found a 
similar tumor develop upon the cornea. 

Numerous reports have been made concerning the accidental coin- 
cidence of diseases of the eye and skin, for example, of ocular affec- 
tions in alopecia areata, which were collated by Froelich {Berl. hi. 
Woch., April 6th, 1891) and present nothing characteristic. When 
mydriasis is found in extensive urticaria (Zunker, Jahr. f. Aug., 
1876, p. 296), this must be regarded as mydriasis due to cutaneous ir- 
ritation. Many illustrations of this kind could be adduced. 

In conclusion, a few words regarding exposure to cold. As the 



DISEASES OF THE SKIN. 263 

results of cold, Mooren mentions a melange of conjunctivitis, severe 
keratitis, episcleritis, retinitis, choroiditis, etc. In three cases the 
eyes of cataract patients, who walked on tlie cold floor in their bare 
feet a week after the operation, were destroyed by fulminant choroi- 
ditis ; in one case the same effect followed nine days after putting on 
a cold shirt. Here the fulminant choroiditis in a latent form was 
undoubtedly present at an earlier period, inasmuch as it is a septic 
process and the carriers of infection do not enter the interior of the 
eye as the result of walking on a cold floor. Such an injurious agent 
may be the exciting cause of an acute exacerbation of an already ex- 
isting process, just as similar factors uiaj excite an acute attack of 
glaucoma in an already diseased eye, but not in a perfectly healthy 
one. 

The same explanation, the acute lighting up of an already exist- 
ing latent process in the affected organ, the locus minoris r^esisten- 
tice, must be accepted in the majority of cases of so-called colds. 
Verj" rarely is there a direct connection between an ocular affection 
which was not previously present and the cooling of a more or less 
extensive surface of the body, for example, a facial paralysis or pa- 
ralysis of the iris immediately after a railway trip at the side of an 
open window. But if the affected individual suffers, for example, 
from syphilis, the case is no longer a pure one, although it is in these 
very cases that the "traumatic" action is undeniable. In a few 
cases I have cured " inflammation of the eye from a cold" by removal 
of a foreign body beneath the upper lid, and which the draught had 
blown into the conjunctival sac. 

The chill or rigor from a sudden breeze, which is usually regarded 
by the laity as undeniable proof that they have caught cold, is a 
symptom of the beginning fever or the rapidly rising temperature, 
i.e., of the already existing disease, while the real cause, the infec- 
tion, may have existed a week or more beforehand, usually in an un- 
noticeable manner. 

Articular rheumatism, which was formerly regarded as a disease 
par excellence due to cold, has proven to be a typical infectious dis- 
ease. In many circles colds play the same role now that " the reces- 
sion of the itch" did in former times. Nevertheless colds and itch 



264 THE EYE IN RELATION TO DISEASE. 

do occur, but they are not at the bottom of everything with which 
they are charged. 

In a measure, insolation may be regarded as the antithesis to a 
cold, although the chief part is here played not by the unusual tem- 
perature, but by the secondary loss of serum in the blood and tissues. 

Hotz {Jahrb. f. Aug.^ 1879, p. 255) mentions six cases of optic 
neuritis in insolation. Moore reports bilateral neuritis with subse- 
quent pigmentation of the optic disc. 

The implication of the eye in rhino-sclerosis will be considered 
when speaking of the respiratory organs, that of so-called myxoedema 
under the heading of constitutional diseases. 



OHAPTEE III. 
DISEASES OF THE DIGESTIVE ORGANS. 

While there are manifold relations between diseases of the skin 
and eye, this is true only to a slight extent of diseases of the digestive 
organs, apart from a few very general occurrences. 

It may first be mentioned that fluids dropped into the conjuncti- 
val sac not infrequently pass through the lachrymal canal into the 
nose and pharynx, are there absorbed and give rise to toxic symp- 
toms. This is observed most frequently in the case of atropine and 
eserine. It should be remembered that a single drop of the ordinary 
solution contains half of the maximum internal dose (according to 
the Pharmacopoeia) for an adult. 

In different individuals such toxic symptoms appear with ex- 
tremely varying rapidity and severity. Especially permeable lachry- 
mal canals probably constitute the most important predisposing fac- 
tor, but in other cases a personal idiosyncrasy is probably important. 

The first symptom consists of a bitter taste and drj^ness in the 
throat. The further symptoms vary according to the nature of the 
poison. 

In dogs and cats a flow of saliva appears almost immediately after 
instillations of atropine. The saliva is swallowed b}^ the dog, and 
expectorated by the cat. 

The constitutional anomalies resulting from protracted and severe 
gastro-intestinal diseases will be discussed in detail in the last sec- 
tion. Abnormal digestive processes are very frequent causes of gen- 
eral anaemia and hydrsemia with their sequelae : feeble accommoda- 
tion, weakness of the external ocular muscles (insufiiciency) . In 
severe cases hemorrhages also take place into the retina, rarely into the 
vitreous body. Neuralgic processes and certain asthenic uveal dis- 
eases, such as iritis serosa, develop by preference in individuals with 
impaired nutrition. 



266 THE EYE IN RELATION TO DISEASE. 

Chronic gastric catarrh in poisoning by alcohol, tobacco, lead, 
etc., by the resulting nutritive disturbance also predisposes to dis- 
ease of the optic nerve ; at least, it is always present at the same 
time. In a measure this is also true of the retinal affections in albu- 
minuria, the latter being often concealed by the symptoms of a 
chronic gastric catarrh. 

The sequelae of gastric and intestinal hemorrhages will be dis- 
cussed under the heading of circulatory disturbances. Similar symp- 
toms are occasionally observed after violent vomiting, especially with 
hsematemesis. As a rule, vomiting causes dilatation of the pupils. 

Chronic pharyngeal catarrh rarely extends to the eye, but smokers 
and drinkers very generally suffer at the same time from conjuncti- 
val catarrh, chiefly from the constant exposure to bad air. This 
cause is essentially traumatic in character. 

Nearly everything that happens between the ages of one and seven 
years is attributed — and not alone by the laity — to teething. Hence 
the literature is quite rich in this respect. 

Apart from abscesses of the gums, especially of the so-called eye- 
teeth, which are occasionally mistaken for dacryocystitis (the re- 
verse is also true in many cases), a definite relation is established 
mainly in reflex neurotic conditions (pupillary changes, paralyses, 
spasms, etc.). 

Conjunctivitis and phlyctenulse are said to result from teething, 
but the former are so frequent that this relationship is very uncer- 
tain. During the teething period disturbances of function can only 
be recognized when they are very marked, and for this reason they 
are undoubtedly overlooked in the majority of cases. 

Numerous reports have been made concerning ocular affections 
and toothache in adults. Keratitis, iritis, phlyctenulse, glaucoma, 
paralyses, asthenopia, amblyopia without lesion, supraorbital neu- 
ralgia, exophthalmus, etc., are mentioned; restriction of accommo- 
dation is mentioned with special frequency. Schmidt (Arch. f. 
Ophth,, XIV, 1, p. 107) found it 73 times among 92 cases, either 
bilateral or unilateral (in the latter event, only on the side of the 
toothache) ; it was most frequent in youth and amounted to 5.0 D or 
more. It rarely gave rise to subjective symptoms. Schmidt believes 



DISEASES OF THE DIGESTIVE ORGANS. • 267 

that it is due to reflex increase of pressure in the eye, analogous to 
the restriction of accommodation occasionally observed as a prodro- 
mal symptom of glaucoma. Pathological anatomy, however, teaches 
that the latter has a much more material local cause. When limita- 
tion of accommodation appears during toothache it probably results 
simply from the lack of vigorous innervation on account of the dis- 
tressing pain. Muscular insufficiency and diplopia, which are occa- 
sionally observed, may also be explained as paresis due to enfeebled 
innervation. 

On the other hand spasm of accommodation has also been ob- 
served as a nervous symptom in toothache. I have seen nictitation 
disappear immediately after removal of a painful tooth. Gosselin 
makes a similar statement concerning supraorbital neuralgia. Neu- 
ralgias, particularly in the first and second branches of the trigemi- 
nus, injection of the eyes and epiphora may undoubtedly result 
from toothache. In view, however, of the very great frequency of 
toothache, the connection must at least be made probable by the fact 
that with the cessation of the latter, or with the removal of the dis- 
eased tooth, recovery or at least striking improvement of the neural- 
gia sets in. A certain degree of relief of neuralgia is probably 
always associated with the removal of a diseased and painful tooth. 

Amblyopia and amaurosis as the result of disease of the teeth 
have been reported several times, — for example, by Lardier {Rec. 
d'OpMli., 1875, p. 87), Gill (Jahr. f. Aug., 1872, p. 373), Metras 
(lb., 1873, p. 217), Keyser (^6., 1872), Samelsohn {ib., 1877, p. 195). 
When the symptoms appear without any visible lesion, the connection 
may be granted. But positive ophthalmoscopic findings make this 
extremely suspicious and lead us to think of a common cause for the 
pain and visual disturbance. 

Hutchinson (^6., 1885, p. 316) observed lagophthalmus from 
spasm of the levator palpebrae superioris during toothache. Blanc 
{ib., 1871, p. 225) claims to have cured a chronic ophthalmia (?) by 
extraction of a tooth. Brunschwig {ib., 1887, p. 302) makes the 
same claim with regard to two cases of iritis with hypopyon. It is 
easy to understand the frequent development of abscesses in the lower 
lid as the result of abscesses around the teeth, especially of the so- 



268 . THE EYE IN RELATION TO DISEASE. 

called eye-tooth. Very rare is purulent inflammation of the orbit 
in caries of the upper teeth. Pagenstecher (Jahr. f. Aug., 1884, p. 
620), Burnett {ib., 1885, p. 16) and Vossius {Arch. f. OpMh., XXX, 
3) have observed cases of this kind. Exophthalmus may also develop 
from serous infiltration of the orbital tissue in the vicinity of the in- 
flammatory focus, and it may disappear rapidly after removal of the 
tooth. Dimmer (Wien. med. Woch., 1883, p. 299) observed metas- 
tatic choroiditis after extraction of a tooth ; Sewill claims to have 
seen the development of cataract after this procedure. JSTeuschueler 
{Jahr. f. Aug., 1889, p. 403) reports the cure of toothache by means 
of prisms. 

On the other hand, it is to be noted that pain in the upper teeth 
on the same side is a frequent symptom of the so-called ciliary pains of 
keratitis, but particularly of iritis and cyclitis. Less frequently is 
there pain in the teeth of the lower jaw on the same side, and still less 
frequently in those of the other side ; these are cases of irradiation 
of pain to adjacent nerve-twigs. Neuralgic toothache may be the 
prodromal sign of glaucoma. 

Symptoms similar to those described are also attributed to the 
irritation of worms. A connection with diminution of accommoda- 
tion and narrowing of the field of vision is conceivable, but can be 
explained with difficulty on account of the absence of pain. In 
former times a striking enlargement of the pupils was regarded as a 
pathognomonic sign of worms in the intestinal canal. I have not 
been able to find any recent data on this subject. It is, indeed, con- 
ceivable that intestinal parasites may discharge excretions which are 
absorbed by the intestines and cause paralysis of the sphincter pu- 
pillse, but this is not very probable. The question merits further in- 
vestigation. 

Furnell {ib., 1871, p. 177) claims to have cured obstinate iritis 
and keratitis and also nyctalopia by means of vermifuges. In this 
connection very fantastic accounts might be quoted. It is evident 
that suggestion plays a prominent part in such cures. 

More intelligible symptoms are produced by taenia solium when 
its six-hooked cj^sticercus is situated in the orbit, eyelids, external 
ocular muscles, beneath the conjunctiva, in the interior of the eye, 



DISEASES OF THE DIGESTIVE ORGANS. 269 

or in the brain. These symptoms will vary according to the locality 
affected. Our present knowledge of the natural history of the tape- 
worm compels us to discredit the statement of Montmeja, that cys- 
ticerci deposit ova within the eye. 

According to Reyher {Deutsch. Arch. f. kl. Med., 1886, p. 43) 
tapeworms, especially bothryocephalus latus, produce pernicious 
anaemia with extreme pallor of the papilla, narrow, slightly colored 
vessels, and spontaneous retinal hemorrhages. The same conditions 
are observed in the ansemia which is connected with the presence of 
the anchylostomum duodenale in the intestinal canal. Slight oedema 
of the face, especially of the lids, is common to both conditions. 

A well-known symptom is the initial oedema of the lids in trichi- 
nosis, and which may be the first objective sign of that condition. 
Emigration of trichinae into the ocular muscles causes pain, inter- 
ference with the movement of the eye in all directions, and drooping 
of the upper lid. Impairment of accommodation, which is often 
present, is explained by the pain caused by convergence, because the 
smooth muscles within the eye are secure against the emigration of 
trichinse. It may also be the result of the action of ptomaines, like 
the mydriasis ; the latter, however, is possibly sympathetic (as the 
result of the pains). All these symptoms occur only in severe cases 
and are then bilateral ; they attain their height at about the fourth 
day and then diminish. Redness and more or less secretion from the 
conjunctiva are also usually present (Kittel, Wien. med. Zschr., 
1871, p. 254). 

Profuse diarrhoeas give rise, particularly in infancy, to xerosis 
conjunctivae et corneae, as in the cholera of adults, by a desiccation 
slough in the inter-palpebral space and subsequent infection from the 
conjunctival sac. In the dry cornea with a somewhat reduced tem- 
perature, however, the micro-organisms do not appear to develop 
with the same rapidity as in other infectious keratitides at a corre- 
sponding age. 

As a general thing the appearance of xerotic keratitis in cholera 
infantum is a sign of impending death, and the latter generally oc- 
curs before perforation of the cornea takes place. But if the general 
disease tends to improve, the process may come to a standstill at any 



270 THE EYE IN RELATION TO DISEASE. 

stage. With the newly awakened activity of the tissues a reactive 
inflammation of the cornea sets in. This checks the further spread 
of the desiccation necrosis and leads to exfoliation of the necrotic 
parts. The ultimate lesion varies according to the extent and depth 
of the necrosis, from a slight patch in the zone of the palpebral fissure 
to a dense leucoma with or without anterior synechia, prolapse of 
the iris, or even total staphyloma of the cornea. The milder forms 
are observed more frequently, because if the process extends very 
deeply, a fatal termination usually occurs. For reasons easily un- 
derstood the disease is almost always bilateral, although it often does 
not exhibit the same intensity in both eyes. The intestinal disease, 
as such, acts as a predisposing factor, because the marked loss of 
fluids in profuse diarrhoea facilitates desiccation in unprotected parts. 
There is evidently at the same time a sort of ptomaine narcosis 
which gives rise to the insensibility of the cornea and the imperfect 
movement of the lids. 

Von Graefe originally regarded this disease as a neuro-paralytic 
keratitis resulting from interstitial keratitis, because numerous so- 
called granular corpuscles were found in the brains of the little pa- 
tients. These are found constantly, however, in the growing brain, 
and hence the diagnosis "encephalitis" is not warranted. The 
longer the cornea is exposed to the air, and the dryer the tissues, the 
greater the liability to the disease. 

We may also mention three cases of corneal xerosis in adults, ob- 
served by Schoeler after strenuous treatment for obesity. 

Immermann {Jahr. f. Aug.^ 1887, p. 250) reports a case of blind- 
ness and subsequent atrophj' of the optic nerve after very profuse 
diarrhoea. 

Conjunctival hemorrhages occur not infrequently in old people 
with brittle vessels from straining at stool. Hemorrhages into the 
retina or vitreous, or into the orbit, are much rarer. Such hemor- 
rhages possess prognostic importance because, as a rule, they are 
forerunners of cerebral apoplexy. 

Profuse hemorrhoidal hemorrhages may cause the same visual 
disturbances as profuse hemorrhages from other organs. In former 
times a number of visual disorders were attributed to suppression of 



DISEASES OF THE DIGESTIVE ORGANS. 271 

hemorrhoidal hemorrhages. In a few cases vicarious hemorrhages 
into the vitreous are said to have been observed, similar to the so- 
called vicarious menstruation. Hemorrhagic glaucoma, ^.e., acute 
glaucoma in an eye whose vessels are diseased, is also said to result 
from this cause, but a direct connection is doubtful. It is certain, 
however, that in inflammatory uveal affections of patients who suffer 
from piles, laxatives or leeches ad anum not alone have a general 
favorable effect, but also exert a favorable influence on the eye disease 
whatever its relations to the hemorrhoids may be. 

In hepatic diseases the eye may be affected in various ways. In 
jaundice the yellow color of the conjunctiva is early noticeable, and 
also lasts longer than the icteric color of the skin. In the diagnosis 
of so-called hsematogenous icterus, for example, in toxic and septic 
processes, the yellow color of the conjunctiva is important because 
the icteric color of the integument may not be pronounced. 

Subjective yellow vision has been observed for a little while at the 
beginning of catarrhal icterus. I have again recently seen a case of 
this kind. We are apt to assume that this S3^mptom results from a 
yellow color of the ocular media if an intense jaundice develops very 
rapidly. In my last case, however, the jaundice was neither very in- 
tense nor had it developed very acutely. The yellow vision reminds 
us exactly of that observed in santonin poisoning, where it is due to 
the fact that the retinal elements at first do not respond to the violet 
end of the spectrum and later not to the red end. It is characteristic 
of the peripheral nature of the symptom that, as in santonin poison- 
ing, shadows are seen in the complementary color, i.e.^ violet. The 
central perception of violet is not disturbed ; the retinal elements have 
merely become insensitive to violet. The coincident night blind- 
ness, which also occurs without yellow vision, develops in an 
analogous manner (torpor retinae, vide p. 34). 

It is probable, therefore, that the symptom is due to the action of 
a ptomaine, which is not produced in every case of icterus, and may 
even be absent in very severe and rapidly developing forms. 

Hemeralopia has been associated with hepatic affections of all 
kinds; compare, for example, Parinaud, Maci, and Nicati {Jahr. f. 
Aug., 1881, p. 395 et seq.). Xerosis of the conjunctiva also occurs 



272 THE EYE IN RELATION TO DISEASE. 

in jaundice (Leber, Parinaud, Snell), although rarely; as is well 
known, it is often combined with hemeralopia {vide p. 34). 

In acute yellow atrophy of the liver, numerous retinal hemor- 
rhages are usually found in the terminal stage, in addition to the 
yellow color of the conjunctiva. The hemorrhages come from the 
septic poisoning, as in septicaemia. The same condition is also ob- 
served, for example, in acute phosphorus poisoning. 

According to Hirschberg bilateral retinitis may develop as the re- 
sult of hepatic diseases. The connection is probably the same as in 
yellow vision, viz., direct action of an injurious substance upon the 
retina. Litten (Deutsch. med. Woch., 1882, No. 13) emphasizes the 
very frequent occurrence of retinal hemorrhages in all kinds of he- 
patic affections which are attended with jaundice. 

Xanthelasma has often been associated with diseases of the liver. 
Very pronounced cases are reported, for example, by Foot {Jahr. f. 
Aug., 1876, p. 447) and Korach {ih., 1881, p. 438). 

Landolt {Arch. f. Oplitli. , XVIII, 1) has observed the coincidence 
of retinitis pigmentosa and cirrhosis of the liver, and has assumed an 
intimate connection between them because the two processes are both 
interstitial in character. He has applied the term cirrhosis retinse 
to retinitis pigmentosa. But their combination is so rare and the 
etiology of the two diseases differs so greatly that a connection be- 
tween them cannot yet be conceded. Cirrhosis of the liver is an in- 
terstitial inflammatory process, beginning with a stage of cellular 
infiltration and enlargement of the organ and ending in marked re- 
traction and diminution of volume ; its cause appears to be a chronic 
infection or toxaemia of some sort. Under the same circumstances 
similar processes may appear in other parenchymatous organs, for 
example in the kidneys, but not a typical retinitis pigmentosa. The 
retinal changes in the latter are those of pure atrophy, especially of 
the nervous elements after destruction of the outer layers of the re- 
tina, combined with pigment emigration from the destroyed pigment 
epithelium. Active inflammatory processes in the retina are entirely 
absent or play a very subordinate part. As in other localities, the 
very moderate increase of connective tissue may be explained ex 
vacuo, but the destruction of the nervous elements is not initiated by 



DISEASES OF THE DIGESTIVE ORGANS. 273 

cellular infiltration of the connective tissue. Retinitis pigmentosa 
and cirrhosis of the liver have in common only the terminal stage, 
the connective -tissue degeneration. 

The chief site of the disease in so-called retinitis pigmentosa is in 
the chorio-capillaris and its nutritive territory. The affection begins 
at the periphery where the meshes of the chorio-capillaris are widest, 
and is then concentrated upon the region where the meshes are nar- 
rowest, the capillaries themselves widest, i.e., in the region of the 
macula lutea. As a result of the imperfect nutrition, the external 
layers of the retina degenerate and later its centripetal fibres. Pro- 
liferating processes, which are merely forerunners of necrosis, are 
found only in the pigment epitheliiun. The final choroidal atrophy 
may be more striking and intense than that of the retina. Unfor- 
tunately there are no anatomical findings in the earliest stage when 
there is merely peripheral torpor retinae and visible changes are still 
entirely absent. 

Even if typical retinitis (preferably chorio-retinitis) pigmentosa 
and cirrhosis of the liver occur together, the former runs a much 
more chronic course than the latter. 

The relation of chorio-retinitis pigmentosa to cirrhosis of the liver 
is a very instructive illustration of the fact that, in the accidental 
coincidence of two diseases, an apparent anatomical similarity may 
lead to the assumption of an internal connection which in reality 
does not exist. Chorio-retinitis with retinal pigmentation and cir- 
rhosis of the liver may both have a common cause, for example con- 
genital syphilis, but then we have to deal, not with a typical retinitis 
pigmentosa, but with much more acute inflammatory processes in the 

eye. 

18 



OHAPTEE IV. 

DISEASES OF THE RESPIRATORY ORGANS. 

The relations between the respiratory organs proper and the organ 
of sight are very slight. The}^ result chiefly from the vicinity to the 
eye of the beginning of the respiratory tract, viz., the nose and its 
auxiliary cavities, the orbit and conjunctival sac. We will therefore 
first consider the diseases of the nose and its cavities, with which it 
is best to include diseases of the ear, because the mode of connection 
of the latter with diseases of the eye is entirely similar. As a mat- 
ter of course, tumors in these localities may penetrate the orbit and 
attack the eye (for example, Meden, Arch. f. Aug., XYI, p. 387), 
but such cases do not interest us here. 

• 
1. Diseases of the Nose 

may ascend through the lachrymal duct to the conjunctival sac, 
or very rarely the opposite path may be followed. Tubercular (lu- 
pous) and certain follicular diseases, epithelial cancer and the like, 
may extend in this way from the eyelids and conjunctiva to the 
nose. During infectious diseases of the conjunctiva the lachrymal 
canals, as a rule, are impermeable on account of the swelling of their 
mucous membrane, and hence the disease does not reach to the lachry- 
mal sac and nasal mucous membrane. 

With far more frequency disease of the nasal mucous membrane 
is the starting-point for the affection of the conjunctiva and cornea. 

As a rule, every acute coryza causes eye symptoms, hypersemia, 
or catarrh of the conjunctiva "so that one cannot see." This is also 
true of so-called hay fever. Occasionally there is an outbreak of 
herpes febrilis upon the eyelids or cornea, which is easily recognized 
by its characteristic form. To this category probabl}^ belongs Deck- 
er's case (Monatsbl. f. Aug., March, 1890) of herpes cornese zoster 
as the result of nasal disease, unless the coincidence was merely acci- 



DISEASES OF THE RESPIRATORY ORGANS. 275 

dental. If herpetic disease has made its appearance on the cornea it 
not infrequently returns with relapses of coryza, and may severely 
distress the patient. 

In chronic coryza we often find hypersemic and chronic catarrhal 
conditions of the conjunctiva which undergo acute exacerbations from 
time to time, usually with the nasal disease, and require local treat- 
ment both of the eye and of the nose. The affection is usually bi- 
lateral, but it is occasionally unilateral. Although the lachrymal 
passages partake in the trouble, there is usually no obstacle to the dis- 
charge of the secretion and no noticeable pathological change in its 
character. At the most — but this is very common — there is epiphora 
on account of the swelling of the mucous membrane, while a sound 
will readily pass. 

Far different and more frequent is the situation when, in chronic 
rhinitis, the formation of ulcers and scabs in the nose occludes the 
opening of the lachrymo-nasal duct. The secretion cannot escape ; 
it decomposes, and gives rise to purulent inflammation of the lachry- 
mal sac with all its sequelae. 

On passing a sound the obstruction is found not at the opening of 
the lachrymo-nasal duct into the nose, but mainly at the opening of 
the canaliculi into the lachrymal sac and at the transition of the lat- 
ter into the lachrymo-nasal duct, about the valvular folds of the mu- 
cous membrane. 

Hence we find (1) diseases of the lachrymal sac constantly re- 
lapsing despite permeability and despite the fact that the sound al- 
most enters of itself, so long as the nasal mucous membrane is not 
sufficiently cured and the constant formation of crusts occludes the 
opening of the lachrymo-nasal duct; and (2) that a dacryo-cysto-blen- 
norrhoea which has not lasted too long and in which there are no bony 
occlusions, may be cured by suitable treatment of the nasal mucous 
membrane and persistent emptying of the lachrymal sac. In many 
cases the patient may be spared the painful treatment with sounds. 
The nasal treatment, however, is not perfectly simple and usually 
lasts a long time, because, as a rule, we have to deal with a disease 
that has endured for years. Nor is it sufficient in all cases (rhinitis 
atrophicans). It is important, however, under all circumstances. 



276 THE EYE IN RELATION TO DISEASE. 

Gruhn (Muench. med. Woch., July 3d, 1888) found disease of the 
nose absent in only two cases among thirty-eight cases of disease of 
the lachrymal sac. 

I have not been able to secure any specific statistics, but can main- 
tain with positiveness that at least three-fourths of the cases of dis- 
ease of the lachrymal sac which have come under my observation 
were caused by chronic rhinitis with formation of crusts. 

Eczematous disease of the nasal mucous membrane very often 
gives rise to inflammations of the eye, particularly in children. It 
may be merely a more or less active catarrh (Horner's eczematous 
catarrh), which is very obstinate unless properly dealt with. This 
category also includes the large majority of diseases of the conjunctiva 
and cornea to which the indifferent term phlyctenular has been ap- 
plied, and which have been called by Horner eczema of the conjunc- 
tiva and cornea. But not every phlyctenular disease of the eye 
merits this name. The isolated eruptions without a trace of eczema 
in any other part of the body may very well be due to some other 
cause. The large majority of the cases, however, are undoubtedly 
eczematous. In nearly 90 per cent, of the cases of phlyctenular dis- 
ease of the conjuctiva and cornea in children, I can prove the co- 
existence of eczema nasi. In addition there is very often a striking 
parallelism between the relapses of the disease of the eye and nose. 

Eczema of the nose may continue for a long time without corre- 
sponding diseases of the eye. But after the latter has developed, 
"when it has found the way," it relapses with every acute exacerba- 
tion of the nasal inflammation. Sometimes the disease is confined to 
one nostril and to the corresponding eye. It is a striking fact, how- 
ever, that disease of the tear passages so rarely occurs, probably be- 
cause eczema does not lead to the formation of crusts, as in other 
forms of chronic rhinitis. 

As a matter of course local treatment of the eye disease, especially 
of severe corneal phlyctenulse, is indispensable. But the constant 
relapses only cease when the nasal affection is cured. 

The nasal mucous membrane is much more often the starting- 
point for eczematous disease of the conjunctiva and cornea, than of 
the skin of the lids. 



DISEASES OF THE RESPIRATORY ORGANS. 277 

In ulcerative destruction of the nasal mucous membrane vigorous 
blowing of the nose may. cause emphysema of the lids. Such cases 
are reported by Newcombe {Lancet, 1874, II, p. 184), Jeaffreson 
{ih., p. 221), Fano {Jahr. /. Aug., 1886, p. 433) and Fieuzal (^6., 
1887, p. 413). 

Whether suppuration in the nose may be the direct cause of iritis, 
as is claimed by Ziem in three cases, appears to me to be very doubt- 
ful, and, at all events, the connection is entirely obscure. 

Hoadley Gabb {Jahr. f. Aug., 1883, p. 549) observed in epistaxis 
after spasmodic cough that the blood escaped through the lachrymal 
duct of the corresponding side. Schmidt-Rimpler {Moiiatshl. f. 
Aug., 1877, p. 375) observed blindness of both eyes after loss of blood 
due to curetting nasal polypoid growths. This case is doubtful be- 
cause the hemorrhage was a slight one. The ophthalmoscope showed 
sinuosity of the veins and slight cloudiness of the papillse. 

Rhinoscleroma will also be discussed here among diseases of the 
nose. It is confined almost exclusively to certain regions (South- 
western Russia, Austria and Central America). The disease con- 
sists of a tumor formation which starts from the mucous membrane 
of the nose or pharynx and develops, after many years, into an ex- 
tremelj^ hard, either flat or nodular, infiltration. It extends chiefly 
in the mucous membrane , but the muscles, cartilage and skin may 
also be attacked. Atrophy and cicatricial retraction do not occur 
until a very late period, and ulceration very rarely takes place. It 
seems to be due to a diplococcus which resembles Friedlaender's pneu- 
mococcus. 

Among eighty-seven cases collected by Wolkowitsch {Arch. f. kl. 
Chir., XXXVIII, p. 356), the eye, including the lachrymal sac and 
lids, w^as involved nine times. The lesions included firm nodules of 
the lachrymal sac with subsequent degeneration and ulceration and ex- 
tension of the process to the middle of the left lower lid (Zeissl) ; a 
fluctuating tumor of the left lachrymal sac, which disappeared on 
pressure (Jarisch) ; right-sided dacryocystitis (Alvarez) ; right-sided 
epiphora (Mandelbaum); bilateral dacryocystitis (Wolkowitsch). In 
four cases firm, hard tumors were found upon the lachrymal sac 
(Weinlechner, Stukowenkoff, Schulthess, and Wolkowitsch). In 



278 THE EYE IN RELATION TO DISEASE. 

Schulthess' case (Deutsch. Arch. f. kl. Med. , XLI, p. 71) the en- 
tire process seems to have started from the mucous membrane of the 
lachrymal sac. 

Gaillard {Jahr. f. Aug., 1887, p. 447) reports a case of thrombo- 
sis of the orbital veins in nasal furuncle and has collected fifteen 
similar cases in literature. 

It remains for us to consider a number of ocular reflexes in dis- 
eases of the nose. Ziem (Berl. kl. Woch., 1889, N"o. 38; Deutsch. 
med. Woch., 1889, No. 5, etc.) and certain American writers claim 
to have observed various "nervous" eye symptoms, such as astheno- 
pia, slight pareses of accommodation, concentric narrowing of the 
field of vision with or without disturbance of central vision, bleph- 
arospasm, etc. , in all kinds of nasal diseases, and to have cured them 
by suitable treatment of the nose. Even in several cases of chronic 
glaucoma, Ziem claims to have obtained at least temporary enlarge- 
ment of the field of vision by galvano-cautery of the nasal mucous 
membrane. In view of the close proximity of the diseased structures, 
it is not astonishing that nervous ocular reflexes of the character 
mentioned occur occasionally, but they possess no further significance. 
Similar phenomena are observed in toothache and in every form of 
severe pain, and disappear spontaneously with the cessation of the 
pain. 

Greater importance attaches to the visual disorders after opera- 
tions on the nasal mucous membrane (galvano-cautery) , and which 
were observed by several writers (Ziem, Centralhl. f. Aug., 1887, 
p. 131; Berger, Arch. f. Aug., XVII, p. 293, and others). In these 
cases the visual disturbance is not infrequently in the shape of the 
we]l-known concentric narrowing of the field of vision, with or with- 
out disturbance of central vision and the color sense. The eye on the 
side operated upon is attacked alone or to a more marked degree, and 
the condition is a temporary one in all cases. Similar symptoms re- 
sult occasionally from painful procedures in the neighborhood of the 
eye. The reflex process is probably the same that we find in trau- 
matic hysteria {vide p. 221), whose symptoms are often confined to 
the immediate neighborhood of the trauma. These are evidently 
the mildest forms of hysteria and might be termed local, temporary 



DISEASES OF THE RESPIRATORY ORGANS. 279 

hysteria or hysteria minor, because the difference is merely quanti- 
tative, not qualitative, like that between the petit-mal and grand-mal 
of epilepsy. 

After galvano-cauterization of the nasal mucous membrane in 
Basedow's disease. Hack {Deutsch. med. Woch., 1880, No. '25) ob- 
served disappearance of the exophthalmus on the operated side. Hop- 
mann {Jahr. f. Aug., 1885, p. 473) appears to have seen a similar 
case, viz., cure of a unilateral Basedow's disease by treatment of the 
nasal mucous membrane. In these cases we also recognize the paresis 
of the sympathetic system following the injury (paralysis of the un- 
striped dilators of the palpebral fissure). 

Trousseau (ibid., 1889, p. 559) claims to have cured two cases of 
blepharospasm, one case of obstinate scotoma scintiUans (ophthalmic 
migraine), one case of mj'driasis and three obstinate asthenopias, by 
treatment of the nasal mucous membrane. Many similar cases could 
be mentioned, but some of them are verj^ doubtful. 

Marckwort (Arch, f, Aug., 1887, p. 452) observed the develop- 
ment of acute glaucoma after the protracted application of cocaine 
to the nasal mucous membrane. This may result in a much shorter 
time, without general cocaine poisoning, b}^ the instillation of a few 
drops of a cocaine solution into the conjunctival sac. 

2. Diseases of the Cavities 

adjacent to the nose exercise, on the whole, the same influence on 
the eye as do nasal diseases themselves, with which they are usu- 
ally associated. Stasis of secretion in the frontal sinuses often gives 
rise to supraorbital neuralgia ; a similar condition in the antrum of 
Highmore gives rise, though much more rarel}", to neuralgia of the 
infraorbital nerve, and these recover after removal of the obstruction 
to the escape of the secretion. For this reason the nasal douche often 
has a favorable influence after all antineuralgics have proven useless. 
Ziem (Monatsclir. f. Ohrenheilk., Aug., 1889, p. 174) cured a case 
of extreme contraction of the field of vision in nasal suppuration 
by restoring the outflow fi'om the antrum, and with its occlusion a 
relapse again occurred. 

Apart from the symptoms of compression and displacement of the 



280 THE EYE IN RELATION TO DISEASE. 

eye and its appendages (exophthalmus, paralyses, atrophy of the 
optic nerve, etc.), which result from tumors, abscesses, etc., of these 
cavities, inflammations of the cellular tissue and abscesses in the 
orbit may develop, and disease of the ethmoid may cause epiphora 
by pressure on the lachrymal passages {vide Berger and Tyrmann, 
"Die Krankheiten d. Keilbeinhoehle u. d. Siebbeinlabyrinthes u. 
ihre Beziehungen zu Erkrankungen d. Sehorgans," Wiesbaden, 
1886). 

Ptosis is not infrequently found in dropsy of the frontal sinuses 
attended b}^ erosion of the bones and dilatation of the sinuses; this 
may cause pressure on the optic nerve. All symptoms may dis- 
appear after opening the cavity, but this is not true of all cases. 

In diseases of the sphenoidal sinuses, caries or necrosis of the 
body of the sphenoid, blindness and defects of all kinds in the field of 
vision may be produced by implication of the adjacent optic nerve, 
chiasm and optic tracts. 

It will be proper to consider now the diseases of the eye which are 
observed in 

3. Ear Diseases, 

because they present numerous points of resemblance to those noticed 
in diseases of the nose and its auxiliary cavities, to which the cavity 
of the tympanum also belongs. 

Irritative symptoms in the external auditory canal and the cavity 
of the tympanum, whatever may be their origin, appear to give rise 
occasionally to reflexes similar to those in diseases of the nasal mu- 
cous membrane. Blepharospasm is mentioned with special frequency, 
for example, in cases of foreign body in the external auditory canal 
(Rampoldi, Annal. di Ottahn., XVIII, 3), in syringing the cavity 
of the tympanum (Ziem, Deutsche med. Woch., 1885, 49), etc. 
Rampoldi repeatedly checked blepharospasm of this nature by drop- 
ping cocaine into the ear. 

Lucae {Jahrh. f. Aug., 1881, p. 152) has several times produced 
"optic vertigo," with apparent motion of objects toward the opposite 
side, by using the air douche from the external auditory canal in 
cases of perforated tympanum. He also observed abduction of the 



DISEASES OF THE RESPIRATORY ORGANS. 281 

globe toward the irritated side. Evidently this was conjugate devi- 
ation of the eyes toward the side of irritation with apparent move- 
ment of objects in the opposite direction. Under certain circum- 
stances, however, the apparent movement of objects appears to take 
place in the same direction as the movement of the eyes {vide Jahr. 
f. Aug., 1883, p. 118). Lucae observed, at the same time, obscura- 
tion of the field of vision, probably the concentric narrowing of the 
field to which attention has often been directed. He believes that 
these symptoms are due to the extension of pressure of the labyrin- 
thine fluid and thence to the subarachnoid cavity of the brain, possi- 
bly to irritation of the dura mater or the tympanic plexus. 

Baginski {Jahr. f. Aug., 1881, p. 153) found that in rabbits the 
injection of water into the cavity of the tympanum produced move- 
ments of the eyes and nystagmus. These were the more marked, the 
higher the pressure and the more pronounced the temperature and 
chemical constitution of the injected fluid. Similar symptoms were 
produced by boring into the labyrinth, if the procedure opened into 
the skull at the same time. He believes that the injected fluid reaches 
the brain (restiform body and ascending root of the trigeminus) and 
there gives rise to these movements. Hoegj^es {(hid.) obtained sim- 
ilar results, but believes they are due to irritation of the roots of the 
acoustic nerve. Touching various parts of the semicircular canals 
with a bristle always produced characteristic associated movements 
of the eye. I also believe that we have to deal in such cases with 
involuntary or voluntary reflexes due to irritation of the acoustic 
nerve. Kipp {Jahr. f. Aug., 1888, p. 434) observed three cases of 
nystagmus in purulent inflammation of the middle ear. The six 
cases {ibid., 1883, p. 520) of opacity of the vitreous with cholesterin 
crystals (sj'nchysis scintillans) in disease of the middle ear were 
probably accidental coincidences. In a case of polyp of the ear, 
Pflueger observed nystagmus whenever the polyp was seized. Cohn 
{Berl kl. Wschr., 1891, No. 43) also observed cases of nystagmus, 
associated with vertigo, on irritation of the diseased ear. 

Urbantschitsch {Wien. med. Blaetter, 1882, No. 42) often noted 
the influence of ear disease (chronic catarrh of the middle ear) upon 
the acuity of vision, either impairment or improvement in one or 



282 THE EYE IN RELATION TO DISEASE. 

both eyes, often an alternation between the two, in the course of the 
same ear disease. No definite relations could be detected, however, 
between the ocular and aural affections. On the other hand Ram- 
poldi (I.e.) claims to have improved hearing by iridectomy in glau- 
coma. Davidson and Dransart claim the same result from iridec- 
tomy in leucoma of the cornea. 

Much more important than these very inconstant nervous symp- 
toms are other and material eye diseases which are observed in puru- 
lent inflammation of the middle ear, in caries and necrosis of the pe- 
trous portion of the temporal bone, etc. Apart from facial paralysis 
owing to destruction or lesion of the nerve in its long bony canal, 
there may also be sensory disturbances or paralyses of the ocular 
muscles, especially of the abducens. These are either temporary, 
and are then due to infiltration or to " remote action" upon the adja- 
cent nerves, or they are permanent and due to destruction of the 
nerves. In perforation into the skull, purulent meningitis with its 
eye symptoms will develop (vide 'p. 150). Cerebral abscesses, espe- 
cially in the temporal lobes, with their characteristic symptoms, 
(vide p. 137) also occur frequently in aural suppurations. Kipp 
(Jahr.f. Aug., 1884, p. 324) even reports two cases of metastatic pan- 
ophthalmia in aural suppuration. 

Zaufal (Prag. med. Woch., 1891, No. 15) recommends ophthal- 
moscopic examination in suppurations of the middle ear in order to 
determine the proper period for operative interference. So long as 
the ophthalmoscopic appearances are normal, there is no danger in 
delay. But as soon as unilateral or bilateral venous hypersemia or 
an indication of neuritis or choked disc, even without disturbance of 
sight, is visible, then the pus must be evacuated at once on account 
of the danger of meningitis, even if no other threatening symptoms 
are present. Zaufal found that the ophthalmoscopic appearances 
again became normal after the operation. Others have made similar 
observations. In my opinion it is not advisable to wait until the 
development of visible ophthalmoscopic findings. In not a few of 
such cases, it would be too late. 

Knaipp {Arch. f. Aug. und Ohr., II, 2, p. 191) has observed iritis 
serosa and keratitis parenchymatosa in combination with so-called 



DISEASES OF THE RESPIRATORY ORGANS. 283 

Meniere's disease which begins suddenly with vertigo, ringing in 
the ears, vomiting, tottering gait and pronounced deafness, and in 
which no constant pathological lesion in the ear has yet been found. 
The real connection between these diseases of the eye and ear is very 
obscure. Pooley (X Y. Med. Eec, Jan. 8th, 1887) found bilateral 
neuritis in a man of forty -three years suffering from this disease, 
and who was attacked, almost at the same time, with disorder of 
sight and hearing ; he also suffered from polyuria, without albumin 
in the urine. The autopsy showed nephritis and softening within 
the cerebrum; the cerebellum appeared normal. In the majority 
of ocular complications of Meniere's disease, which is evidently 
not an anatomical unit, we probably have to deal with accidental 
coincidences. 

Stein {Jahr. f. Aug., 1887, p. 381, and Centralhl. f. Aug.., Jan., 
1887) claims that he has produced cataract in guinea-pigs by means 
of tuning-forks, and all the more readily, the younger the guinea- 
pig and the longer the vibrations of the tuning-fork. Evidently we 
have to deal here in part with hj'pnotic conditions due to the mon- 
otonous auditory sensations which lasted hours and days; this is 
further supported by the drowsiness and the cessation of the pupillary 
reaction. There also seems to have been a development of mild nu- 
tritive disturbances in the lens, interfibrillary accumulation of fluid 
ap.d the like, probably as the result of insufficient ingestion of food ; 
this acted more rapidly in young than in old animals. Permanent 
opacity of the lens was not produced. What might not be expected 
from such experiments in man? Insanity would be the least. 

4. Effects of Respiration and its Abnormalities upon 

the Eye. 

In inspiration there is slight dilatation, in expiration, slight con- 
traction of the pupil, as we can readily observe upon ourselves if suit- 
able precautions are adopted. According to v. Platen the reception 
of oxygen and the excretion of carbonic acid during the respiration 
of mammals are increased by the action of light on the retina. Ac- 
cording to Urbantschitsch {Centralhl. f. Aug., 1887, p. 513) light also 
stimulates and darkness enfeebles the auditorv function. 



^84 THE EYE IN RELATION TO DISEASE. 

Reyher (Jahrb. /. Aug., 1870, p. 303) observed pronounced my- 
driasis during sudden dyspnoea from swallowing a large piece of 
meat " the wrong way ;" it disappeared immediately after the dis- 
lodgement of the meat by vomiting. This is easily explained by the 
marked suction action of inspiration upon the contents of the blood- 
vessels, when the air passages are occluded and the lungs contain 
only a moderate amount of air. 

When the nostrils are closed during vigorous expiration, the air 
occasionally escapes through the lachrymal duct, and this produces 
a peculiar tickling sensation in the inner angle of the eye. Dilata- 
tion of the lachrymal sac and its distention with air may also be pro- 
duced by labored breathing, for example, in pulmonary affections 
(Starcke, Rau). 

Irritation of the conjunctiva in little children often produces sud- 
den cessation of breathing. This is readily observed in treating blen- 
norrhoea neonatorum with the mitigated stick. In a boy of four years 
suffering from atropine poisoning, Guttmann (Deutsch. med. Woch., 
March 29th, 1888, p. 255) observed, not closure of the lids, but ces- 
sation of respiration, on touching the cornea. Hence it seems to be 
one of the lower reflexes, like the deep inspiration resulting from vig- 
orous stimulation of the skin, for example, in cold douches and the 
like. Kuert (Wien. med. Presse, 1891, No. 21) noticed cessation of 
spasm of the glottis on touching the cornea, but this could be done 
more easily and certainly by tickling and irritating the nasal mu- 
cous membrane. 

In dyspnoea (emphysema, etc.) venous stasis in the retinal veins 
is visible with the ophthalmoscope. There may even be hemorrhages 
into the retina, rarely into the vitreous. Hemorrhages into the con- 
junctiva also occur under such circumstances. It is well known that 
attacks of asthma occur preferably in the dark, and that the burning 
of a light at night decidedly diminishes their frequency. 

In acute suffocation the pupil is generally, though not always, nar- 
row, and hemorrhages, often only punctate, occur into the conjunc- 
tiva and retina. The latter are often not seen until the autopsy. The 
hemorrhages also often occur beneath the integument of the lids and 
are found occasionally in all the vascular parts of the eye and its vi- 



DISEASES OF THE RESPIRATORY ORGANS. 285 

cinity (Schlemm's canal, Petit's canal, etc.). In chronic suffocation, 
in which similar hemorrhages may finally be produced, the retinal 
vessels, particularly the veins, appear with the ophthalmoscope to 
be unusually dark, often almost black, as the result of overloading 
the blood with carbonic acid. 

In two cases of Cheyne- Stokes breathing, Robertson {Lancet^ 27, 
XI, 1886) found that the pupils grew constantly larger during the 
return of respiration, and constantly smaller as the respirations ceased ; 
this was uninfluenced by illumination of the eye. In one case, in- 
deed, the reaction of the pupil to light was abolished {vide p. 171). 

As is well known, sneezing is often produced on forcible opening 
the eyes of children suffering from photophobia. This is particularly 
true of conjunctivitis and keratitis phlyctenulosa. As a rule, nasal 
disease (eczema) is present in such cases, but this is not a necessary 
factor. Even in adults an intense light stimulus — for example, look- 
ing at the sun — may cause one or more acts of sneezing. In others, 
this effect is only produced under certain conditions, — for example, in 
one of my acquaintances only immediately after meals, but then 
with absolute certainty. Fere {Neurol. Centralbl, 1890, p. 732) 
could prevent this in himself by displacing his four puncta lachry- 
malia with serres fines; he then experienced no desire to sneeze. 
This reflex, he claims, necessitates irritation of the nasal mucous 
membrane by the abnormally secreted tears ; hence it did not always 
occur immediately. Whether this etiology holds good for all cases 
must be left undecided. 

Sneezing, blowing the nose and coughing may give rise to hem- 
orrhages in all vascular parts of the eye and its vicinity, most fre- 
quently in the conjunctiva, eyelids and retina. In such cases there 
are very often coincident changes in the vessels, particularly athe- 
roma, and these naturally constitute a predisposing factor. If there 
are ulcerative processes in the lachrymal sac, or a solution of continu- 
ity has taken place in its bony walls or in those of the adjacent cavi- 
ties of the nose, all these expiratory efforts may give rise to emphy- 
sema of the lids or in the orbit. What strange things may happen 
is shown by Malgat's case {Rec. d' Ophth., 1890, No. 4) . A lady was 
compelled to sneeze several times during a meal, and soon afterward 



286 THE EYE IN RELATION TO DISEASE. 

felt a violent pain in the region of the inferior lachrymal duct. Three 
days later a little abscess developed there and discharged a piece of 
salad 2 mm. long and 1 mm. wide. Malgat had previously treated 
the lady for keratitis, and therefore excluded an abnormality of the 
lachrymal passages, but this must probably have been present. In a 
young girl spontaneous luxation of the globe in front of the upper lid 
was observed by Depontot {Jahresb. f. Aug., 1885, p. 458) as there- 
suit of Sneezing. I have also observed this, as the result of sneezing, 
in Basedow's disease. 

The expiratory efforts of coughing, blowing the nose and sneez- 
ing may be very painful when there is an internal inflammation of 
the eye. This is also observed very often in the onset of myopia, 
during its acute exacerbations, and in these cases can be relieved 
considerably by vigorous pressure on the eyes. 

Ocular affections are, on the whole, infrequent in 

5. Diseases of the Respiratory Tract Proper. 

We may mention the not uncommon occurrence of herpes cornese 
during the course of bronchitis and acute pneumonia. After this 
complication has once appeared, it may relapse — and always on the 
same eye — in subsequent attacks. Bilateral herpes cornese is very 
rare. 

Kampoldi {Centralhl. f. Aug,, Nov., 1886) calls attention to the 
occurrence of sympathetic nerve symptoms in pulmonary diseases. 
It is especially in disease at the apex that the sympathetic may be 
implicated, and irritative as well as paralytic phenomena of vasomo- 
tor and oculo-pupillary character maybe observed. In one of bis 
cases there was bilateral mydriasis in febrile catarrh of both apices, 
and it diminished with the improvement of the pulmonary affection. 
In the second case there was pulmonary infiltration, especially of the 
left apex, together with left mydriasis which passed subsequently 
into myosis; atrophy of the left half of the face and slight ptosis 
developed at the same time. 

, After a profuse secretion had been expectorated for six weeks in 
a case of purulent bronchitis, Adler {Jahrh. f. Aug., 1889, p. 240) 
observed, in addition to chill, vomiting, fever aiad pain in the left 



DISEASES OF THE RESPIRATORY ORGANS. 287 

shoulder, a metastatic conjunctival abscess on the left side, to the 
outer side of the cornea; the abscess discharged and healed in a 
month. Posterior synechise and opacities of the vitreous were 
present in the eye itself, but the organ was preserved. The 
staphylococcus pyogenes aureus was found in the pus discharged 
from the abscess. 

Cerenville {Rev. Med. de la Suisse Normande^ 1888, 1 and 2) 
collated twenty-one cases, including six of his own, of cerebral symp- 
toms after operation for empyema. The symptoms consisted gener- 
ally of a sudden epileptic attack with wide pupils, although they were 
sometimes contracted at the start. The convulsions were generally 
unilateral, but not always on the operated side. Disorders of speech, 
pareses, vasomotor disturbances, amaurosis, scotoma scintillans and 
phosphenes may continue for a time after the seizure, usually for a 
few minutes only. The attacks themselves lasted from five minutes 
to sixteen hours. In one case the ophthalmoscope revealed a pale, 
cloudy papilla and narrow vessels; in two cases, hypersemia and 
hemorrhages along the vessels ; similar conditions may also be present 
in the brain. The operation wound was occasionally very sensitive; 
the pupils then dilated upon touching the wound or the exposed pleura, 
or they became unequal (like the unilateral or bilateral mydriasis 
upon irritation of the skin) . 

Two months after repeated operations for empyema, Handfort 
{Brit. Med. Jouni., Nov. 3d, 1888) observed the development of 
neuro-retinitis, first on the left side, then on the right, with almost 
complete blindness. At the end of eleven days vision again returned, 
but finally there was complete amaurosis. At first there was also 
right hemiparesis, later hemiplegia, aphasia, etc. The autopsy 
showed bilateral cerebral softening, especially of the angular gyri 
and the occipital lobes, i.e., an almost symmetrical embolic process 
in the brain. 

Of course embolic pysemic affections maj^ originate from purulent 
diseases wherever situated, but they appear to start rarely from af- 
fections of the pleura and air passages. 



CHAPTER Y. 
DISEASES OF THE CIRCULATORY ORGANS. 

We will here consider only the abnormalities in the amount and 
circulation of the blood, and the direct diseases of the heart and ves- 
sels. The abnormalities in the constitution of the blood, among 
which the higher grades of so-called anaemia and hydreemia belong, 
fall in the main under the category of constitutional anomalies 
and infectious diseases, and will there be considered. For the affec- 
tions of the vasomotor nerves, vide the diseases of the nervous sys- 
tem (p. 119). 

In general anaemia and hypersemia (plethora), the eye is not 
usually affected to a noticeable extent, and even if it were, it could 
not be regarded as a manometer. Indeed, the amount of blood in 
the eye may be exactly the reverse of that in other parts. In anaemic 
conditions, in particular, we very often find the signs and symptoms 
of conjunctival hyperaemia, and these are usually quite obstinate in 
such cases. It is only in high grades of general anaemia or venous 
hyperaemia that a corresponding condition is noticed in the retinal 
vessels. If these exhibit distinct venous hyperaemia, we will hardly 
ever have to deal simply with general "plethora," but complications 
on the part of the respiratory organs (emphysema, asthma) or the cir- 
culatory organs (valvular lesion, fatty heart) will be found at the 
same time. If, as the result of the stasis, hemorrhages have occurred 
into and around the eye (conjunctiva, retina, vitreous body, etc.), 
we may conclude, almost with certainty, that vascular lesions are 
present. It is true, however, that these are only demonstrable ana- 
tomically, and are recognized clinically merely by the appearance of 
the hemorrhages. Hypertrophy of the left ventricle may or may not 
be present. 

Under normal conditions of excretion from the eye the ocular 



DISEASES OF THE CIRCULATORY ORGANS. 289 

pressure is essentially a function of the blood pressure within the 
vessels. But increase or diminution of the blood pressure is not alone 
shown by a corresponding change in the ocular pressure — which may, 
however, be almost entirely compensated, especially in increased 
blood pressure, by increasing outflow — but may also produce phe- 
nomena visible with the ophthalmoscope. 

Gradual diminution of the pressure and quantity of the blood, 
which must be assumed in many so-called anaemic conditions, must 
have become very pronounced before it is visible with the ophthal- 
moscope. We then find a pale, in the highest gTades almost chalky 
white, papilla and narrow vessels with contents of a lighter color. 
But a change in the red color of the fundus itself is rarely or never 
seen with certainty in purely anaemic conditions. The visible changes 
are mainly attributable to the changed contents of the vessels. The 
only symptom which points directly to the diminished blood-pressure 
is pulsation of the retinal arteries on slight pressure upon the eye. 
Even spontaneous pulsation is occasionally found in intense anaemic 
conditions. Pressure sometimes causes entire disappearance of the 
veins. 

After prolonged duration of such conditions we find a tendency to 
spontaneous retinal hemorrhages; their absorption is attended by 
the formation of white patches and rarely gives rise to slight pig- 
mentation of the retina. These hemorrhages often recur if the gen- 
eral condition is not cured. In such cases vascular disease, either 
directly as the result of defective nutrition of the vessel walls or fa- 
vored by it, must be assumed ; it has even been demonstrated anatom- 
ically, though not in all cases. We will return to this subject in 
the discussion of constitutional anomalies. 

In a few extremely anaemic females, between the ages of seven- 
teen and twenty years, I saw the complete picture of retinitis albu- 
minurica, although not a trace of albumin was discovered in the 
urine. The affection was very obstinate but finally recovered com- 
pletely after lasting six to nine months. Such cases seem to be very 
rare. 

If the blood pressure suddenly falls considerably, the elastic intra- 
ocular pressure constitutes an obstruction to the circulation of the 
19 



290 THE EYE IN RELATION TO DISEASE. 

retina, which is not found in this way in other vascular tracts. The 
arteries pulsate and become visibly narrower; the circulation of 
blood becomes irregular. The papilla grows pale, everything grows 
dark before the patient's eyes and there is concentric narrowing of 
the field of vision, with which the attack of syncope begins. The 
same thing is observed when, after great excitement, great exhaustion 
ensues. The coincident subsidence of central vasomotor innerva- 
tion entails imperfect supply of blood, especially to the head. On 
several occasions I became aware, from the suddenly developing arte- 
rial pulsation during ophthalmoscopic examination, of an impending 
attack of syncope, and was able to guard the patient against falling 
from the chair. 

With the restoration of vascular tonus and filling of the vessels 
this usually disappears without any bad effects. In rare cases there 
is a more or less sudden onset of unilateral or bilateral disturbance of 
vision, amounting even to complete blindness. This may either be 
permanent or may undergo improvement. As a rule, complete res- 
toration does not occur. Disturbances of vision and the color sense, 
defects of the field and, very rarely, a central scotoma are left, as in 
other diseases of the optic nerve. 

The ophthalmoscopic appearances in such cases of "amblyopia 
and amaurosis after loss of blood" are often negative at the onset, or 
at the most we find a somewhat pale papilla and narrow vessels. 
More or less complete atrophy of the optic nerve develops at a later 
period. One finding is known as retrobulbar neuritis, and corre- 
sponds, as a rule, to a hemorrhage into the trunk of the optic nerve 
or its sheaths. In other cases there is neuritis and choked disc with 
considerable opacity of the retina and papilla, often with hemor- 
rhages and white patches. Samelsohn observed a retinal hemorrhage 
develop with beginning improvement of vision after the restoration 
of circulation. 

Such conditions are occasionally seen after hemorrhages of the 
most varied kinds, after hsematuria, profuse menstruation, abortion, 
epistaxis, venesection, but most frequently after gastric hemorrhage 
and haematemesis. Even violent vomiting alone may produce such 
results. Sometimes the disorder of vision occurs only after repeated 



DISEASES OF THE CIRCULATORY ORGANS. 291 

hemorrhages, or it may appear after the first hemorrhage and be ab- 
sent in succeeding ones. 

Three weeks after the beginning of the disease, Ziegler (" Beitr. 
z. path. Anat. u. Phys.," Bd. II) found fatty degeneration of the 
supporting elements of the optic nerve and the innermost layers 
of the retina, most pronounced in the scleral portion of the nerve ; 
cell infiltration was wanting. These findings remind us of the 
ischsemic foci of degeneration in the brain and heart muscle. Zieg- 
ler attributes them to local contractions of the vessels owing to gen- 
eral anaemia. 

Baques {Annal. cli Ottalm.,X.^, 3)' has studied the histological 
changes in the retina in temporary anaemia. If the latter lasted an 
hour or more, retinal hemorrhages and oedema developed at the end of 
eight to ten days. The ganglion cells become dropsical ; vacuoles and 
signs of degeneration appear in the cells of the internal granular layer, 
with proliferation of the connective-tissue elements of the supporting 
fibres. These findings are not, however, directly applicable to our 
clinical cases. 

Special attention should be paid to the following points: 1. Am- 
blyopia and amaurosis after hemorrhage are rare and occur only in 
individuals who are otherwise not in a healthy condition, so that, in 
addition to the loss of blood, there must be some other predisposing 
factor. Not a single case occurred in the entire campaign of 1870- 
71. Fries {Monatshl. f. Aug., 1876) found only 5 cases of wounds 
among 106 cases — one case of hemorrhage, lasting half an hour, from 
a small spirting artery, three perforating wounds of the chest (hence 
not a simple hemorrhage) , and one insufficiently described case. In 
all these cases recovery occurred in from three to seventy- two hours. 
This is otherwise not the rule, even in cases of venesection which, as 
a matter of course, is always done in sick individuals. 

2. The typical cases generally occur after the lapse of several days 
(usually five to eight days, even twenty-one days or more), i.e., at a 
time when the blood pressure has risen and the circulation has been 
restored. The onset is usually more or less sudden. 

3. Similar conditions are sometimes observed after trifling hem- 
orrhages, when the factor of diminished blood pressure does not come 



292 THE EYE IN RELATION TO DISEASE. 

into question. Strictly speaking, these cases do not belong in this 
category, because there is evidently a coincident disease of the vessels 
at the site of the hemorrhage and in the optic nerve. 

In all cases the cause appears to be a hemorrhage into the optic 
nerve (which may have been absorbed at the time of examination) , 
resulting from necrobiosis (fatty degeneration) of the previously dis- 
eased walls of the vessels. This condition is consequent on protracted 
disturbance of nutrition from insufficient supply of blood. 

On account of the rapidly sinking blood pressure, very little or no 
blood enters the vessels of the retina and optic nerve, and this is true 
in a measure of the cranial vessels. The result is that things grow 
black before the eyes, and blindness and syncope set in. Under cer- 
tain predisposing conditions necrobioses develop in the walls of the 
vessels during the depression of circulation. With returning circu- 
lation the syncope ceases and vision is restored. It is only after a 
certain lapse of time that solutions of continuity occur in the walls 
of the vessels, and hemorrhages ensue. These are comparatively 
harmless in the retina, but in the optic nerve they cause signs of re- 
trobulbar neuritis with subsequent atrophy. If the hemorrhage is 
situated far back, the ophthalmoscopic appearances are at first nega- 
tive. If it is situated near the papilla we find visible changes with 
opacity and stasis, because the current in the optic nerve and its 
sheaths normally flows toward the cranial cavity. 

It is also easy to understand that a central scotoma occasionally 
develops. Cerebral disorders of vision, such as homonymous hemi- 
anopsia, blindness with intact reaction of the pupils, etc., are also 
observed at times. Such cases appear to be due to temporary dis- 
turbance of the circulation within the cranium, and the prognosis 
is favorable. 

Early puncture of the chamber is said to have acted favorably by 
diminishing the ocular pressure (v. Graefe), but I find no reference 
to this point in later writings. If the vessels are brittle this treat- 
ment would favor the development of retinal hemorrhages, and I 
would advise against it. 

In disorders of the circulation we not infrequently notice visible 
pulsation of the retinal vessels, not alone confined to the papilla, as 



DISEASES OF THE CIRCULATORY ORGANS. 293 

in the physiological venous pulse, but often extending far toward the 
periphery of the retina. 

In aortic insufficiency there is almost constantly a pulsation of the 
arteries, synchronous with the radial pulse, and alternating with en- 
largement of the veins. The conditions are very favorable to the de- 
velopment of pulsation in the vessels of the eye. As a result of the 
compensatory hypertrophy of the left ventricle the blood pressure is 
greatly increased during systole, and markedly diminished during 
diastole on account of the reflux of blood through the insufficient 
valves (Becker, Arch. f. Ophtli.^^KNH, 1, Bindi Monatshl. f. Aug., 
1871, p. 80; Quincke, Berl kl. Woch., 1868, :^o. 31). But a visible 
arterial pulse may also be absent in aortic insufficiency, especiallj' 
if the latter is combined with a certain amount of stenosis, or it 
is absent during rest and appears when the heart's action is in- 
creased. It may disappear under the influence of digitaHs. A 
similar condition is observed much more rarely in other cardiac 
lesions, and also in Basedow's disease and in extreme anaemia and 
chlorosis. 

Alternate reddening and pallor of the optic papilla may aJso be 
observed in aortic insufficiency (Jaeger), and this capillary pulse is 
analogous to the corresponding phenomenon in the finger-nails. This 
symptom is, however, rarely pronounced. 

Ocular symptoms may be produced either directly in the eye, or 
indirectly from the brain, by extensive diseases of the vessels, partic- 
ularly atheroma, arterio-sclerosis, fatty degeneration and certain 
specific diseases, such as syphilis, albuminuria, leukaemia, chronic 
infections and poisons, etc. The different anatomo-pathological forms 
can rareh' be distinguished from one another with the ophthalmo- 
scope. Often as such vessel -changes are found post-mortem in the 
retina and choroid, they are seen with the ophthalmoscope with com- 
parative infrequency, although not so rarely as was formerly supposed. 
For example, Raehlmann found visible changes in the retinal vessels 
twenty-four times among forty-four cases of general arterio-sclerosis 
{Zeitschr. /. U. 2Ied., XYI, p. 606). 

The walls of the arteries and veins have a white border (periarte- 
ritis and periphlebitis) ; in places they are thickened into a spindle 



294 THE EYE IN RELATION TO DISEASE. 

shape. Often there are several thickenings upon the same vessel so 
that the lumen may be narrowed to complete obliteration. The walls 
of the vessels sometimes contain j^ellowish, fatty patches, especially 
upon the papilla. If the vessel remains tolerably transparent in en- 
dophlebitis and endarteritis, the column of blood at the diseased spot 
merely appears thickened. If the narrowness of the vessels, espe- 
cially of the arteries, indicates considerable diminution of the blood 
pressure, pulsation is not infrequently observed. According to Raehl- 
mann lateral displacements and flexions are more frequent than real 
changes of calibre. 

In the further course of the process the vessels may be obliterated. 
Sinuosities and dilatations make their appearance, particularly on the 
veins, and often alternate with constrictions. More or less numerous 
miliary aneurisms may also form upon the arteries. But such cases 
are very rare (Michaelsen, Hirschberg, Schleich, Liebreich, Schmall,, 
Raehlmann) , and can only occasionally be demonstrated post mortem 
(Liouville). 

The recovery of such a disease of the vessels is occasionally noted, 
as, for example, by Seggel, in a case of syphilis. 

Such processes occur more frequently and usually much more ex- 
tensively in the choroid than in the retina. Naturally their demon- 
stration is generally possible only after death. 

More striking than these diseases of the vessels, which are often 
discovered only after very careful examination, are their results, 
viz., the hemorrhages which occur either spontaneously or upon com- 
paratively slight provocation (bending, lifting, warm or cold bath, 
etc.). They may occur into any vascular part of the eye, but they 
are usually most striking in the conjunctiva, retina and vitreous hu- 
mor. They may be absorbed, but in the retina an extensive, white 
discoloration is often left either at the middle or at the periphery. 
Relapses are common. Inasmuch as disease of the vessels in 
the eye points to a similar affection of the vessels within the cra- 
nium, — among thirty-five cases of atheroma in the skull Raehlmann 
found in twenty of them a similar affection in the conjunctiva, retina 
or vitreous — spontaneous hemorrhages, or those which occur after 
trifling causes, are often forerunners of cerebral hemorrhages. If the 



DISEASES OF THE CIRCULATORY ORGANS. 295 

latter are not directly fatal, they may in turn give rise, according to 
their location, to central disturbances of vision. In old people we 
have to deal chiefly with atheroma, in younger people with other 
diseases of the vessels. In both cases the prognosis is unfavorable, 
except in syphilis, and even the later effects may be disastrous. 

According to v. Graefe arterio-sclerosis may be the cause of hem- 
orrhagic glaucoma. It would probably be more correct to say that 
this affection is glaucoma in an eye whose vessels are diseased, and 
that this explains its clinical peculiarities. 

According to Michel and his pupils, atheroma of the carotid may 
give rise to cataract. When the latter is unilateral, atheroma can 
almost always be demonstrated on palpating the carotid, or, if the 
atheroma is present on both sides, it is more pronounced on the side 
of the diseased eye. Other observers have been unable to confirm 
these statements, and this agrees with my experience. Indeed, I 
have not infrequently noticed the opposite state of affairs, viz., very 
slight or no atheroma upon the side of the cataract. For this very 
reason I do not believe, as Michel is inclined to assume, that negative 
results are due mainly to insufficient examination. Moreover, it is 
difficult to see how atheroma of the carotid may be the direct cause 
of cataract, while a similar affection in the ciliary body or processes 
might very well give rise to it. But this lesion has not been proved 
to exist. 

Hemorrhoids formerly played a great part in the etiology of dis- 
eases of the eye. At the present time such a relation is hardly men- 
tioned. A profuse hemorrhoidal hemorrhage might occasionally give 
rise to " amblyopia or amaurosis from loss of blood," but this appears 
to be comparatively rare. 

We have already referred to retinal pulsation in aortic insuffi- 
ciency. Schmall {Arch. f. Ophth., XXXIV, 1, p. 37) observed it 
twice in twentj'-two cases of mitral disease, and once in obliteration 
of the pericardial cavity. In such cases other factors must have 
given rise to a decided increase in the difference between the systolic 
and diastolic blood pressure. 

General venous congestion or cyanosis as the result of heart dis- 
ease will also be noticeable in the eye. In the last stages of valvular 



296 THE EYE IN RELATION TO DISEASE. 

lesions the cyanosis, oedema and dyspnoea will produce their effects 
on the eye, will give rise to hemorrhages, etc. 

In a case of dilatation of the heart without valvular disease, Knapp 
(Jahresb. f. Aug., 1870, p. 337) observed general cyanosis, aneuris- 
mal murmurs in many parts of the body and excessive hypersemia 
of the retinae with innumerable thick and sinuous arteries and veins. 

The hypertrophy of the left ventricle, which occurs quite con- 
stantly in the later stages of chronic renal disease, was formerly re- 
garded as the cause of so-called retinitis albuminurica. It has been 
found, however, that the latter is due to definite disease of the ves- 
sels and occurs with or without hypertrophy of the heart. 

In fatty heart there is not infrequently extensive disease of the 
vessels which may give rise to ocular hemorrhages. I have been un- 
able to recognize a connection between fatty heart and the arcus 
senilis (fatty degeneration of the corneal tissue). As a rule, fatty 
heart could not be demonstrated in those very cases in which the 
arcus senilis appeared at a prematurely early age. 

Diseases of the heart and vessels may also give rise to thrombosis 
and embolism in the eye. If the emboli are infectious they result in 
a specific new formation, an inflammation or suppuration (ulcerative 
endocarditis). If the embolus is not infectious, its effects may vary. 
Emboli of the choroid produce slight symptoms because of the large 
size of the choroidal vessels and the numerous anastomoses which 
prevent a notable interference with circulation. 

A choroidal embolus looks like a chorio-retinitic patch. It forms 
a whitish, somewhat prominent spot with indistinct borders, over 
which the retinal vessels pass or in which they disappear. In the 
latter localities there is considerable opacity of the innermost layers 
of the retina. The visual disturbance is essentially a scotoma cor- 
responding to the situation of the embolus. After a time the opacity 
disappears and more or less atrophy and irregular pigmentation of 
the choroid are left. Vision may be entirely restored. Such condi- 
tions are usually seen accidentally (because the subjective symptoms 
are slight), especially during convalescence from certain infectious 
diseases (small-pox, typhoid fever) . Sometimes several foci develop 
at the same time or successivelv. 



DISEASES OF THE CIRCULATORY ORGANS. 297 

Embolism of the retinal arteries runs a much more severe course, 
because they are terminal arteries and are connected with the cho- 
roidal vessels merely by a few capillary anastomoses at the border of 
the papilla. 

If the embolus lodges in the trunk of the central artery of the re- 
tina, sudden blindness will develop. With the ophthalmoscope the 
arteries appear empty, the veins narrow, and occasionally the col- 
umn of blood in them is interrupted; the papilla is pale. Diffuse 
opacity of the retina soon makes its appearance. This is most dense 
at the entrance of the optic nerve and merely allows the region of the 
fovea centralis to shine through as a "cherry-red spot." As a rule 
the blindness remains permanent, although the retinal circulation 
may be restored in a few days through the anastomoses at the en- 
trance of the optic nerve. The papilla becomes atrophic, the arteries 
remain narrower and occasionally degenerate into connective-tissue 
threads. 

In embolism of a branch of the central artery the latter is merely 
empty beyond the site of the embolus. The opacity is confined to the 
corresponding vascular province, and a corresponding loss in the field 
of vision is demonstrable. After a while the observer may follow 
the dcA^elopment of the hemorrhagic infarction in the occluded vascu- 
lar region. Numerous hemorrhages appear which may be absorbed 
at a later period, but as a rule leave considerable pigmentation of the 
retina. Patches of fatty degeneration and glistening crystals are also 
not infrequently seen in the degenerated retina. Later, there is par- 
tial atrophy of the optic nerve, and although vision may remain fair 
for a long time, there is a general tendency to impairment and to 
complete atrophy of the optic nerve. 

The embolus itself may be visible with the ophthalmoscope, and 
has also been found post-mortem in a number of cases. But this is 
not always possible, and its origin is often clinically obscure. Sud- 
denly developing arterial thrombi may produce the same appearances. 
The emboli and thrombi within the cranial cavity, which give rise 
to eye symptoms, have already been discussed (page 135). 

In aneurism of the aorta or innominate, vasomotor and oculo-pupil- 
lary sympathetic symptoms are often found on the corresponding side. 



298 THE EYE IN RELATION TO DISEASE. 

Initial irritative symptoms give place later to paralytic symptoms 
(ptosis, myosis, enophthalmus, etc.). Such aneurisms may also give 
rise to retinal pulsation and, if the optic nerve is directly involved, 
occasionally lead to neuritis and choked disc. Aneurisms of the inter- 
nal carotid may grow toward the orbit and produce the symptoms of 
"pulsating exophthalmus." Although the latter is usually the result 
of a traumatic aneurism of an orbital artery, ligature of the corre- 
sponding common carotid is the sole remedy. As a matter of course 
it is only indicated when compression of the latter artery causes dis- 
appearance of the symptoms. Recovery was effected in about half 
the cases of operation, but relapses may also occur. Nettleship {Brit. 
Med. Journ.^ 1882, I, p. 381) observed panophthalmitis develop in 
the corresponding eye a few days after ligature. The patient died 
later of cerebral abscess. 

Diseases of the thyroid gland and hypophysis cerebri may give 
rise to eye symptoms. In diseases and neoplasms of the thyroid, vaso- 
motor and oculo-pupillary sympathetic symptoms may appear. As 
the result of pressure on the trachea, a goitre may cause symptoms of 
suffocation, with cyanosis and visible venous hyperaemia of the ret- 
ina. The most important diseases of the thyroid, such as Basedow's 
disease, myxoedema, cachexia strumipriva, etc., will be considered 
under the head of constitutional anomalies. 

Diseases of the hypophysis, particularly tumors, give rise not in- 
frequently to local symptoms, owing to the close proximity to the 
chiasm and optic tract. Paralysis of the ocular muscles is not un- 
common. The hypertrophy of the hypophysis in acromegaly has been 
mentioned on page 201. 



CHAPTEE VI. 
DISEASES OF THE URINARY ORGANS. 

Among the diseases of the urinary apparatus, the principal ones 
to be considered are those formerly known as Bright's disease, now 
preferably included under the term albuminuria. This unscientific 
name indicates a symptom, not a disease, but it is serviceable for 
the reason that the affections of the visual apparatus which are 
here described occur in the most varied anatomical and clinical 
diseases of the kidneys in which albumin is found in the urine. 

The integument of the face and eyelids takes part in the general 
oedema of acute nephritis or of the terminal stages of chronic affec- 
tions of the kidneys. The lids, particularly the lower one, may be 
oedematous at a time when nothing can be discovered in other parts. 
Temporary oedema occurs at a very early period, but permanent 
oedema is only noticed, as a rule, when other parts (ankles, etc.) are 
also oedematous. On the other hand, oedema of the legs and even 
marked ascites may have been present for a long time without no- 
ticeable oedema of the lids, 

CEdema of the conjunctiva (chemosis) appears to be very rare. 
Brecht (Arch. f. Ophth., XVIII, 2, p. 120) reported a case which 
was associated with detachment of the retina ; later the retina again 
became attached. 

The affections of the eye in albuminuria are either intraocular or 
intracranial. Among the former the most important are the affec- 
tions of the optic nerve and retina. Hypersemia of the papilla and 
retina, retinitis, neuritis, neuro-retinitis, choked neuritis with or 
without hemorrhages are found not infrequently in albuminuria, in 
rare cases even choked disc, which differs in no respect from the 
same condition when due to other causes. Such findings often lead 
to a recognition of the renal affection which had previously given 



300 THE EYE IN RELATION TO DISEASE. 

rise only to general, vague symptoms, such as headache, malaise, 
digestive disturbances, etc. 

The characteristic retinitis and neuro-retinitis albuminurica are 
distinguished by two features, viz. , whitish patches and hemorrhages, 
which may either be combined or occur separately. 

An especially characteristic feature is the presence of whitish and 
yellowish patches, which often look greenish-white on examination 
in daylight, situated mainly in the inner layers of the retina. At 
the very start a few are seen in the region of the macula and 
toward or upon the papilla ; later they become more numerous and 
are apt to form a stellate figure around the fovea centralis. At a 
later period they become still more numerous and coalesce in part, 
so that finally the entire fundus is covered with whitish and yellow- 
ish-white patches which are usually sharply defined. The larger 
patches conceal the retinal vessels, either entirely or in places. The 
macula lutea and the vicinity of the entrance of the optic nerve form 
the point of culmination of the disease, but as a rule the fovea cen- 
tralis remains clearly visible as a red spot. The patches diminish 
rapidly in number toward the periphery of the fundus. An irregu- 
lar light-brown pigmentation is seen not infrequently in the larger 
patches. 

The ophthalmoscopic appearances change slowly and often remain 
the same for a long time. A few patches disappear, new ones ap- 
pear, others grow smaller or larger. On the whole, however, a ten- 
dency to increase is unmistakable. Complete absorption is hardly 
ever observed unless the renal disease disappears. 

Hemorrhages are much less characteristic. They are often scanty 
in numbers but sometimes very numerous. As commonly occurs, 
they are in streaks upon the papilla and in its vicinity, and farther 
toward the periphery they grow rounder. They are generally found 
closer to the periphery than the white patches ; they rarely exceed 
the size of the papilla. The hemorrhages may be entirely absorbed 
or slight pigmentation may be left, but as a rule relapses occur. 
Their transition into white patches is sometimes noticeable; they 
then assume a whitish color, which starts either from the middle or 
from the periphery. This condition is also observed in other retinal 



DISEASES OF THE URINARY ORGANS. 301 

hemorrhages, particularly in cachectic individuals. For a time this 
transformation was regarded as characteristic of the hemorrhages in 
pernicious anaemia. 

The picture of retinitis and neuro-retinitis albuminurica consists 
of the patches and hemorrhages just described. If the optic nerve is 
implicated to a marked extent, more or less atrophic discoloration of 
the nerve becomes noticeable at a later period. 

The affection is usually bilateral, though it does not always begin 
at the same time and is not equally developed in the two eyes. Uni- 
lateral cases are not very rare. 

In a number of cases retinal folds develop, and there may even be 
detachment of the membrane. This may lead to loss of sight, but it 
may also disappear completely. Such cases are found particularly 
in the albuminuria of pregnancy, and may recover completely after 
delivery. Hirschberg {Jalir. f. Aug., 1884, p. 387) describes double 
retinitis albuminurica followed by detachment of the retina in a man 
of twenty-two years, and Anderson (z6., 1888, p. 571) reports a de- 
tachment of the retina in chronic nephritis in a child. See Lieb- 
reich's "Ophthalmoscopic Atlas." 

White streaks and thickenings of the walls of the vessels, similar 
to those described on page 293, also appear. In extensive disease of 
the retina this is concealed in great part by the patches and hemor- 
rhages. It is visible, however, before the occurrence of true retini- 
tis, and admonishes us to examine for albuminuria. 

The disturbance of vision varies greatly. It is often slight but 
may also be very pronounced, especially in hemorrhages into the 
macula. It is often strikingly disproportionate to the ophthalmo- 
scopic appearances, being usually very slight in comparison with the 
extensive changes in the fundus. The impairment of vision is greater 
when the optic nerve is affected (retrobulbar neuritis), as shown by 
the subsequent atrophic discoloration of the papilla. Vision often 
varies without corresponding ophthalmoscopic changes. Complete 
blindness is very rare, and occurs almost exclusively in atrophy of 
the optic nerve and detachment of the retina, or in coincident " ursemic 
amaurosis." Disorders of the color sense and definite changes in 
the field of vision do not belong to the clinical history of retinitis al- 



302 THE EYE IN RELATION TO DISEASE. 

buminurica, and are hardly ever noticed except when the optic nerve 
is also affected. In one case I observed subjective green vision which 
lasted several days. 

Anatomical lesions are found particularly in the arteries, veins 
and capillaries. The small arteries and capillaries are very much 
thickened, especially the intima, so that the lumen is narrowed, 
thrombosed and finally occluded (hyaline thickening, sclerosis) . The 
walls of the vessels have a waxy look but do not give the reaction of 
waxy degeneration. According to Duke Charles Theodore of Bava- 
ria, this sclerosis is due to transuding white blood globules which re- 
main in the intima and degenerate. The capillaries exhibit numer- 
ous dilatations, and small dissecting aneurisms are found in the ar- 
teries. 

This degeneration of the vessels is found not only in the retina, 
but also — and often to a much greater degree — in all vascular parts 
of the eye, the choroid, ciliary body, iris, conjunctiva, and especially 
the chorio-capillaries. The latter not infrequently contain inflam- 
matory foci. 

Infiltrations of round cells, nuclear proliferation and hyperplasia 
of the connective tissue are also found in parts of the retina, but are 
not very pronounced. 

The retinal hemorrhages are found wherever the vessels extend, 
i.e., into the intergranular layer. They generally take place from 
capillaries and veins (Weeks), and many contain numerous white 
blood globules. 

There is almost always extensive oedema of the retina, often form- 
ing large cavities which are filled with a filamentous coagulated fluid. 
This gives rise not infrequently to the production of retinal folds, 
and later to detachment of the retina. 

Granular or fatty degeneration of Mueller's supporting fibres is 
occasionally noticed. 

The white patches, which are visible with the ophthalmoscope, 
consist in great part of more or less extensive fatty degeneration of 
the tissue. They may also be composed of hemorrhages in the stage 
of absorption, accumulations of granulo-fatty cells and sclerotic gan- 
glion cells and nerve fibres. According to Treitel the characteristic 



DISEASES OF THE URINARY ORGANS. 303 

stellate figure in the macula results from accumulations of granule - 
fatty cells, and must be attributed to the absorption of tissues in a 
condition of fatty degeneration. 

The rods and cones may long remain normal ; in other cases they 
appear swollen. The pigment epithelium is usually unchanged, but 
the amount of pigment is often diminished ; it sometimes appears 
thickened and swollen. 

Treitel found amyloid granules in the chiasm and optic tract. 

We have to deal accordingly with a disease of the vessels, mainly 
sclerosis, not alone in the retina but in all the vascular parts of the 
eye. All other lesions are secondary, including the hemorrhages, 
oedema, formation of folds and detachment of the retina, fatty de- 
generation and other necrobioses. These secondary changes are 
manifested chiefly in the retina, because its arteries are end arteries 
and circulatory disturbances are not compensated as readily as in 
other places by a collateral supply. Disease of the choroidal vessels 
may be much more marked without giving rise to such nutritive dis- 
turbances. With regard to the pathological anatom}^ of retinitis 
albuminurica, vide Leber (Graefe-Saemisch, Bd. Y, p. 573), Duke 
Charles Theodore of Bavaria (" Beitr. z. path. Anat. des Auges bei 
Nierenleiden," Wiesbaden, 1887), and Weeks (J.rc/i. /. Aug., XXI, 
p. 54). 

The albuminuric affections of the retina occur in all forms of ne- 
phritis, even in the acute forms (scarlatina) . In the latter they are 
much rarer than in certain chronic forms. They are rare in waxy 
kidnej^s and, according to Bull, are only found in this disease when 
the waxy degeneration occurs in contracted kidneys. They are 
equally rare in the large white kidney, or parenchymatous nephritis 
in the stage of fatty degeneration (Lej'den, Charite-Annalen, YI, 
p. 228) . They occur most frequently in the terminal stage of con- 
tracted kidneys. Life is rarely prolonged longer than one year, at 
the most two years ^ after the discovery of the retinal affection. 

Retinitis albuminurica may be produced by whatever gives rise 
to the different forms of nephritis, viz., acute and chronic infectious 
diseases, acute and chronic poisoning, constitutional anomalies, preg- 
nancy, etc. After pregnancy detachment of the retina as well as re- 



304 THE EYE IN RELATION TO DISEASE. 

covery are comparatively frequent. After other causes, apart from 
acute infections and poisons, recovery is rare. The condition devel- 
ops mainly at an advanced age, but it may occur even before the 
period of puberty. Among 103 cases collected by Bull the youngest 
was five years old. 

Unilateral retinitis albuminurica is not extremely rare. Bull (iV. 
Y. Med. Journ., July 31st, 1886) describes ten cases. Cheatham 
{Amer. Med. Assn., 1885, Vol. V, p. 150) found in a case of left-sided 
retinitis that only the left kidney was diseased. Yvert {Rec. 
d'Ophth., 1883, p. 145) observed left retinitis in a man of forty-eight 
years. At the autopsy the right kidney was found entirely absent, 
the left was in the condition of large white kidney. But this does 
not permit the inference that in disease of one kidney the retinal 
affection will be one-sided. 

In retinitis albuminurica and the previously mentioned affections 
of the fundus in albuminuria, the diagnosis is not infrequently made 
with the ophthalmoscope, because the other symptoms of the disease 
are often very vague. The frequency of retinal disease varies from 
seven to thirty per cent, according to different writers. The lower 
figure is probably nearer the truth. 

The prognosis is the same as that of the primary disease, i.e., it 
is bad, because the same vascular changes are found constantly in 
the brain. Hence, the cases with hemorrhage are more unfavorable 
than those with fatty degeneration alone. Temporary improvement 
occurs frequently, but recovery is possible only when the primary 
disease is capable of recovery, for example, in the acute nephritis of 
scarlatina and other infectious diseases, in pregnancy, when abortion 
or premature labor may be induced, etc. Even in such cases the 
acute nephritis is often followed by a chronic affection, or the former 
apparently recovers but returns at a later period . Even when recov- 
ery from renal and retinal affections takes place, permanent blindness 
may result from atrophy of the optic nerve (Graefe-Saemisch, Bd. 
VII, p. 83). Recoveries are most frequent in pregnant women, and 
may take place even after detachment of the retina. Such a com- 
plete recovery from severe disease of the kidneys and retina as is re- 
ported by Adamuek (Centralhl. f. Aug., 1889, p. 98) is very rare. 



DISEASES OF THE URINARY ORGANS. 305 

The retinal affection is either the result of extensive disease of the 
vessels which attacks at the same time the kidneys, retina and other 
organs, or, as in the large majority of cases, it is the result of long 
existing renal disease. In the former event the noxious agent acts 
at the same time upon the vessels of the kidney, retina and uvea, 
brain, etc. ; in the latter event, the insufficient excretion of harmful 
products of disassimilation gradually causes a sort of self-infection 
which, like all chronic infections and poisons, induces disease of the 
vessels. The consequent disturbance of circulation is easily com- 
pensated in many places, but in tissues which are supplied with end- 
arteries (cerebral cortex, retina, etc.) nutritive disorders and necro- 
biosis occur in the part supplied by the vessel. In the retina they are 
apt to begin in the non-vascular centre of the macula lutea, where 
fatty degeneration in the nerve-fibre layer gives rise to the well-known 
stellate figure. QEdema, hemorrhages, etc., develop at a later period. 
If the walls of the vessels are especially brittle as the result of the 
disease, hemorrhages will appear from the start. For this reason 
such cases have a more unfavorable prognosis. 

Great importance was formerly attached to the hypertrophy of 
the left ventricle, which is a constant feature of the final stage of 
chronic renal disease, and it was regarded as a necessary link between 
disease of the kidneys and retina. This theory has not been con- 
firmed. When there is disease of the vessels, the hypertrophy ma}- 
favor the occurrence of hemorrhages, but it is often present when 
there is no affection of the retina, and the latter is not infrequently 
diseased when the left ventricle is normal. 

Hemorrhages into the conjunctiva occur occasionally during the 
course of retinitis, and Talko (Jahr. f. Aug., 1872, p. 353) even saw 
them precede the retinal affection. Samelsohn (Virch. Arch., Bd. 
59, p. 257) observed hemorrhages into both lower lids previous to a 
pure hemorrhagic retinitis albumin urica. Wharton Jones describes, 
as a complication, a hemorrhage into Tenon's capsule with exoph- 
thalmus and blindness. 

Ophthalmoscopic appearances which are similar to those of albu- 
minuria may be foimd independently of the latter, — for example, in 
leukgemia, diabetes, severe anaemia, after profuse hemorrhages (vide 



306 THE EYE IN RELATION TO DISEASE. 

p. 290), occasionally even without any findings. But it must be re- 
membered that albumin may be temporarily absent from the urine in 
renal disease, and, in view of the comparative rarity of retinal affec- 
tions from the causes just mentioned, albuminuria may be excluded 
only after repeated examinations. Some of the retinal affections 
observed in diabetes mellitus must be attributed to coincident albu- 
minuria. 

I have seen retrobulbar neuritis of one eye {i.e., hemorrhage into 
the optic nerve) with blindness in a case of albuminuria ; the other 
eye was attacked a year later by pure hemorrhagic retinitis which 
spared the blind eye. Hemorrhages into the optic nerve have also 
been demonstrated post mortem (Duke Charles Theodore, I.e.). 

Anderson {Jahr. f. Aug., 1888, p. 571) observed detachment of 
the retina in chronic nephritis in a child. 

According to Deutschmann albuminuria is also the cause of cata- 
ract, but Ewetzky and others have shown that albuminuria is not 
more frequent among cataract patients than in other individuals of 
the same age. 

Iritis is observed occasionally and, in the absence of any other 
cause, may be attributed to albuminuria, particularly as the latter is 
often associated with extensive disease of the vessels of the iris so 
that a very slight exciting cause will produce iritis. I have observed 
two cases of this kind, but they appear to be quite rare. Despite the 
extensive vessel disease in the choroid, visible choroiditic changes 
are rare, probably because they are concealed by the pigment epithe- 
lium. They are often found on autopsy. 

Chorio-retinitis is mentioned a number of times in descriptions of 
the ophthalmoscopic appearances, for example, by Kepincki {Arch. f. 
Aug., 1888, p. 388), who also reports a case of embolism of the cen- 
tral artery in albuminuria. Schreiber {Jahr. f. Aug., 1878, p. 300) 
also attributes a case of disseminated choroiditis to the same cause. 

A notable circumstance is the rarity of hemorrhagic glaucoma 
even in the purely hemorrhagic form of retinitis albuminurica. 
Cases have been reported by Weeks {I.e.), Mooren {Jahr. f. Aug., 
1886, p. 309), Guaita {ihid., 1875), and others. 

Among the intracranial ocular symptoms of albuminuria we may 



DISEASES OF THE URINARY ORGANS. 307 

mention paralyses of the muscles and so-called ursBmic amaurosis. 
Both are much rarer than changes in the fundus visible with the 
ophthalmoscope. 

Little is found in literature concerning paralyses of the ocular 
muscles in albuminuria. Finlayson {Jahr. f. Aug., 1877, p. 240) 
reports right abducens paralysis due to a hemorrhage into the pons. 
Foerster (I.e.) makes no mention of these paralyses. They are so fre- 
quent, however, that in every case of sudden or rapidly developing 
paralysis of the ocular muscles with the character of basilar, root, or 
nuclear paralysis, the urine should be examined for albumin. The 
cause generally appears to consist of a hemorrhage in the region of 
the nerve roots or nuclei, possibly even in the nerve itself. Sclerosis 
also occurs in the nerves of the ocular muscles, as Leber demonstrated 
anatomically in the abducens. 

The paralyses usually recover rapidly with or without treatment, 
but often undergo relapses in the same or in other muscles. I have 
recently seen three cases of this kind in rapid succession: 1. Abdu- 
cens paralysis as the sole eye symptom in albuminuria of fifteen years' 
standing, which had been left after typhoid fever ; it relapsed twice 
in a few months, and then the patient died. 2. A left trochlear par- 
alysis — on the right side hemorrhages were found in the optic nerve 
— in contracted kidneys of unknown duration ; death in six months. 
3. A complicated external ophthalmoplegia in a man of twenty-four 
years ; the albuminuria succeeded typhoid fever two years before. 
On the right side the trochlearis was first attacked ; then, while this 
was recovering, the internal rectus and the other external muscles 
supplied by the motor oculi ; finally, attacks of unilateral and bilateral 
ptosis. The paralyses recovered rapidly ; the right internus remained 
paretic longest, alternating with the inferior rectus. Soon afterward 
right ptosis again developed for several days, and then I lost sight of 
the patient. The ophthalmoscopic appearances and the internal ocu- 
lar muscles were always entirely normal, and syphilis could be ex- 
cluded with certainty. 

The muscular paralyses also appear to be terminal symptoms of 
albuminuria, and are certainly indicative of changes in the cerebral 
vessels similar to those which are found in the retina. 



308 THE EYE IN RELATION TO DISEASE. 

Ursemic amblyopia or amaurosis is more frequent than muscular 
paralyses, but is much less common than the retinal affections (about 
one per cent). As the name indicates it is a part of uraemia, and is 
therefore observed particularly in those forms of nephritis in which 
ursemic attacks are more frequent (scarlatina, pregnancy). When 
the nephritis is capable of recovery, ursemic blindnses may also re- 
cover. Otherwise the attacks indicate the beginning of the end. 

The disturbance of vision is bilateral, usually develops suddenly 
or at least rapidly, and generally passes into complete blindness. 
The ophthalmoscopic appearances are negative. The reaction of the 
pupils to light is usually retained, an indication of the cortical site of 
the blindness. It is commonly preceded for some time by headache. 
Ursemic blindness may also form part of a general ursemic attack 
and persist after the latter. The restoration of sight is sometimes 
sudden and complete, for example, on the fourth day in Monod's case 
{Gaz. des Hop., 1870, p. 113). Usually the restoration of sight 
takes twenty-four to thirty-six hours. 

The secretion of urine is checked or diminished, the urine has a 
high specific gravity and contains a good deal of albumin. CEdema, 
headache, vomiting, spasm, etc., are also generally noticed ; the pulse 
is hard and tense. 

A combination with retinal disease is comparatively rare ; the lat- 
ter is then the prior condition. Retinal disease is more frequent dur- 
ing the chronic course of renal affections ; ursemic disorder of sight is 
more frequent in acute nephritis or, at least, in acute exacerbations. 

There may also be other cerebral focal symptoms, such as hemi- 
plegia, unilateral epilepsy, aphasia, etc. 

The pupil may be contracted or dilated, and may or may not react 
to light. In pure cases the reaction to light is unchanged ; when it 
is absent, the optic nerve or primary optic ganglia must be impli- 
cated. In cases of this kind there are not infrequently visible evi- 
dences of stasis in the papilla of the optic nerve. Litten (Jahr. /, 
Aug. ) found absence of the reaction of the pupil to light once in four 
cases; in this case each ursemic attack was accompanied by pro- 
nounced swelling of the disc which was visible with the ophthalmo- 
scope. 



DISEASES OF THE URINARY ORGANS. 309 

Mydriasis is generally present during eclampsia, and Wernigk 
(Diss. Erlangen, 1887) found that in artificial ursemia from occlusion 
of the ureters or extirpation of the kidneys, the first sign of the urae- 
mic attack was mydriasis, with pallor of the fundus (vascular spasm, 
probably from direct action of the poison upon the muscular coat of 
the walls of the vessels) and convulsions. The internal and external 
ocular muscles may take part in the convulsions (convergence, con- 
jugate deviation, etc.). 

After enucleation of an eye Hogg {Lancet^ June 12th, 1875) ob- 
served ursemic blindness in the other eye which was already affected 
with retinitis albuminurica ; partial detachment of the retina occurred 
later, followed by replacement. 

Uraeniic disorder of vision is evidentlj^ the effect of a poison, 
either urea or the extractive matters of the urine. The latter is more 
probable. Acute self-infection takes place from insufficient excretion 
of poisonous products of disassimilation. By long-continued vascular 
spasm this induces partial or total anaemia of the brain, which is 
manifested, in individual cases, in certain places of least resistance. 
The coincident increase in blood pressure causes transudation and 
oedema in the brain, and this may even result in visible evidences of 
stasis in the optic nerve. 

Foerster's case {I.e., p. 231) of a man suffering from albumin- 
uria, who became hemeralopic in bed, is perhaps to be regarded as a 
rudimentary uraemic disorder of vision. 

Temporary amblyopia and blindness in infectious diseases, espe- 
cially malaria, may be the result of coincident renal disease, but may 
also occur independently. 

Not all cases that appear to be uraemic on superficial examination 
prove to be so on more careful investigation. This is illustrated by 
Plenk's case (Jah7\ /. Aug., 1874, p. 400) of sudden blindness in re- 
tinitis albuminurica without uraemia, but with narrow retinal vessels 
(retrobulbar neuritis), and Weber's case (^6., 1873, p. 376) of blind- 
ness lasting two weeks, beginning six hours after a very painful 
labor, without eclampsia or albumin. The latter case must be inter- 
preted as "traumatic hysteria." 

Oglesby {Jahr. /. Aug., 1877, p. 241) saw double neuritis with 



310 THE EYE IN RELATION TO DISEASE. 

hemorrhages in hsematuria. Jogelson {ih., 1888, p. 573) reported 
double optic neuritis followed by atrophic discoloration of the papilla, 
which caused complete blindness within a few days ; six weeks later 
vision had improved to f . This occurred in a woman who suffered 
from retention of urine after remaining all night in a cold room. 



CHAPTEE Til. 
DISEASES OF THE SEXUAL ORGANS. 

We have to consider not only the relations of the eye to morbid 
processes, but also to certain physiological conditions, such as men- 
struation, pregnane}^, parturition, childbed, etc. We will also take 
up certain affections of the new-born which are connected with the 
process of parturition. 

Chlorosis, severe anaemia and the like are included among consti- 
tutional anomalies. It is true that they develop as the result of in- 
flammations and diseases of the uterus and its surrounding parts, but 
the symptoms are the same as in those cases which are due to other 
causes. 

The affections common to both sexes will first be discussed, then 
those peculiar to each sex. 

I. Masturbation is common to both sexes, and it has been regarded 
as the cause of numerous affections of the eye. In view, however, 
of its frequency and the comparative rarity of the latter, we must be 
cautious in asserting a direct causal relation between the two. Foerster 
(Z.c, p. 102) mentions a large number of cases in which "pronounced 
hypersemia, catarrhal inflammation and trachomatous infiltrations, 
which otherwise recover rapidly in young people," improved very lit- 
tle or not at all in masturbators between the ages of twelve and twenty 
years. Landesberg {Jahr. f. Aug., 1881, p. 327) also attributes cases 
of obstinate, often relapsing conjunctivitis to masturbation, and like- 
wise a case of impairment of accommodation and one of unilateral cen- 
tral scotoma. Power {Jahr. f. Aug., 1887, p. 301:) maintains that 
masturbation in males at the period of puberty leads to functional dis- 
orders such as photopsia, muscular asthenopia, blepharospasm, some- 
times even to impairment of vision and pallor of the optic nerve. 
Hutchinson (Ophth. Hosp. Rep., YIII, 1) reports vitreous opacities 



312 THE EYE IN RELATION TO DISEASE. 

and even relapsing retinal hemorrhages, leading to blindness, in 
young people in whom no other cause but masturbation or excessive 
ejaculation could be found. Dieu (Journ. d^OpMh., I, p. 188) cured 
pronounced amblyopia by operation for phimosis. It appears to me, 
however, that a direct connection between masturbation and the eye 
trouble is very doubtful in these cases. 

Excessive masturbation very often leads to neurasthenia and allied 
conditions, and in these the above-mentioned functional disorders of 
the eye and hypersemic conditions, especially of the conjunctiva, are 
not uncommon. As regards other conditions, it may be said that 
the orgasm occurring in masturbation may act as an exciting cause 
of a hemorrhagic process (hemorrhages into the optic nerve, retina, 
vitreous, detachment of the retina) , especially in an already diseased 
organ. When the vessels are brittle every vascular excitement is 
injurious, such as lifting, bending over, a tight collar, etc. 

Coitus may also act as an exciting cause of hemorrhages in an 
already diseased organ, especially in males, but for evident reasons 
this cause is often concealed. In one of these cases I observed large 
retinal hemorrhages, which afterward resulted in hemorrhagic glau- 
coma and complete blindness. It is evident that the walls of the 
ocular vessels had been previously diseased. 

For lack of a more suitable place we may here discuss the gonor- 
rhoeal diseases of the genital mucous membrane. As is well known, 
these are often the source of infection of the conjunctiva (blennor- 
rhoea neonatorum and gonorrhoeal conjunctivitis of adults). An in- 
teresting circumstance is the development of the latter from washing 
the eyes with urine, which has been used as a household remedy 
(Armaignac, Jahr. f. Aug., 1880, p. 291). Gonorrhoea may also be 
the cause of metastatic diseases of the eye, especially of different forms 
of iritis. These exhibit marked clinical similarity with so-called rheu- 
matic iritis in articular rheumatism. They are often associated with 
spontaneous coagulation of the fluid in the chamber (so-called lens- 
shaped or gelatinous exudation, spongy iritis), but exhibit no other 
peculiarities. This form of iritis, which is observed almost exclu- 
sively in men, is usually bilateral and often returns with relapses of 
the gonorrhoea or alternates with inflammation of the joints. 



DISEASES OF THE SEXUAL ORGANS. 313 

As a rule, the iritis is associated with inflammation of the joints, 
especially of the knee and ankle, and the clinical similarity to rheu- 
matic iritis is thus increased. Foerster (/.c, p. 86) mentions a 
number of cases in which the inflammation of the joints and the iri- 
tis relapsed, but not the gonorrhoea. 

The pus in the knee-joint may contain gonococci as well as other 
inflammatory excitants, and is often found to be the product of a 
mixed infection. These are evidently secondary affections, probably 
due to the formation of ulcerations. 

II. Very little can be said of diseases of the sexual organs 
which are peculiar to men. Hypochondria and neurasthenia are 
found very often in those who cannot properly perform the 
sexual function. Spermatorrhoea formerly played a great part 
as a causal factor of both affections. Now the former is geneally 
regarded as a result of neurasthenia. Conjunctival hypera^mia, 
weakness of accommodation, weakness of the interni, and the 
common slight narrowing of the field of vision are very frequent 
symptoms, while tangible anatomical changes are hardly ever pres- 
ent. 

Dieu {Journ. d'Ophth., I, p. 188) found that pronounced amblyo- 
pia, which he attributed to masturbation, was rapidly cured almost 
entirely by operation upon a congenital phimosis. 

III. There are numerous affections of the organ of vision which 
have been brought into connection with the sexual life of women and 
with diseases of the female sexual organs (Foerster, '' Handb. d. 
Aug.," von Graefe-Saemisch, Bd. VII; Hutchinson. Ophth. Hosp. 
Rep., IX, 1 ; Mooren, Arch. f. Aug., X, supplementary vol. ; Geisler, 
Berl. M. Woch., 1880, p. 216; Cohn,. "Uterus u. Auge," Wiesba- 
den, 1890, etc.). 

Menstruation will be first considered. The influence of normal 
menstruation on the normal eye is almost 7iil; that of abnormal men- 
struation on the normal eye is very slight, while the influence upon 
a diseased eye or one that has a tendency to disease may be very con- 
siderable. 

The first appearance of menstruation is sometimes preceded by 
other hemorrhaofes which cease with the onset of the former. For 



314 THE EYE IN RELATION TO DISEASE. 

example, in one case Dor (Jahr. f. Aug., 1884, p. 389) observed bi- 
lateral hemorrhages into the vitreous. 

In normal menstruation eruptions, usually herpes, sometimes ap- 
pear upon the lids (Landesberg, Centr. f. Aug., May, 1883). In an 
extremely rare case (Ransohoff, Mon. f. Aug., June, 1889) the herpes 
appeared upon the cornea and returned with each menstrual period. 
Blue rings around the eyes, slight oedema of the lids, especially the 
lower one, are not infrequent during normal menstruation and are 
perfectly harmless. 

According to Vance (Jahr. f. Aug., 1872, p. 343), congestion of 
the fundus oculi is found in the majority of cases in which disorders 
of the central nervous system appear during menstruation. 

According to Finkelstein (Diss. Petersburg, 1887) concentric nar- 
rowing of the field of vision is noticeable during normal menstrua- 
tion. It begins two or three days before, reaches its maximum on 
the third or fourth day of menstruation, and disappears three or four 
days later. There is also said to be slight contraction of the field for 
colors, and in a few cases green was mistaken for yellow. This is 
probably merely a part of the general malaise during menstruation, 
resulting from the preceding distention of all the blood-vessels. These 
hysteroid disorders of sight are occasionally quite pronounced, as in 
Bock's case {Wien. med. Zeit., 1891). 

The increased congestion and the greater blood pressure prior to 
menstruation may cause exacerbations of already existing eye disease 
or of a " predisposition" to such disease (for example, to phlyctenu- 
lar disease of the cornea and conjunctiva in nasal eczema), and the 
affection of the eye may thus assume a four weeks' type like the quo- 
tidian and tertian types of malarial regions. This occurs in the most 
different kinds of disease; relapse of hordeola in seborrhoea of the 
edges of the lids (Dianoux, Galezowsky, Pfiueger) , iritis after cata- 
ract operation (Mooren), herpes cornese (Ransohoff, I.e.), paralysis 
of the motor oculi (Hasner, Prag. med. Woeh., 1883, No. 10), in- 
flammations of the lachrymal duct, etc. In one case Hirschberg 
(Berl kl. Woeh., 1872, p. 579) observed that for many years the 
menses were always preceded by pains in the region of the liver and 
small of the back, together with jaundice and yellow vision. Trous- 



DISEASES OF THE SEXUAL ORGANS. 315 

seau {Ann. d^Ocul.^ 115, p. 242) reports a case of iritis with hypo- 
pyon which appeared two or three days before each menstrual 
period and also relapsed at the corresponding periods during preg- 
nancy. 

The increased congestion may cause temporary slight exophthal- 
mus, for example, with coincident enlargement of the thyroid and 
acceleration of the pulse (Cohn, yion. /. Aug., 1867, p. 351), or it 
may increase existing exophthalmus, particularly in Basedow's dis- 
ease. Cohn's patient evidently suffered from Basedow's disease, 
although all the symptoms disappeared in the intervals. 

Under certain circumstances, such as disease of the vessels, men- 
struation may also induce hemorrhages, for example, into the optic 
nerve (Leber, " Handb. v. Graefe-Saemisch," Bd. V, p. 819). 
Whether hemorrhages can be produced in perfectly healthy eyes 
seems to be doubtful, but hemorrhages into the anterior chamber, 
vitreous, and even from the conjunctiva (Perlia, Muench. med. 
JVoch.y Feb. 21st, 1888) may for a long time attend menstruation. 
Such hemorrhages also occur as vicarious menstruation, without co- 
incident hemorrhage from the uterus. A neuro-retinitis which re- 
lapses during the menses (Rampoldi) may not be regarded as vica- 
rious menstruation, but as an exacerbation of an already existing 
disease. 

Santos Fernandez {Jahr. f. Aug., 879, p. 255) claims to have ob- 
served a case in which congenital blindness suddenly recovered, at 
the age of twenty -two years, with the appearance of the first men- 
strual period. 

The influence of abnormal menstruation is more pronounced. 
Conditions prior to the beginniug of menstruation, either dysmenor- 
rhoea or amenorrhoea, sudden suppression of the menses and the 
menopause give rise, on the whole, to similar symptoms in the organ 
of vision. 

In many cases the menstrual disorder is due to a constitutional 
anomaly, ansemia, chlorosis, scrofula; in others it is the result of 
chronic uterine disease which in turn may give rise to similar con- 
stitutional anomalies. Hence we often find menstrual disorders as- 
sociated with those eye symptoms which are attributable to constitu- 



316 THE EYE IN RELATION TO DISEASE. 

tional disorders, asthenopia in all its forms, conjunctival hypersemia, 
hysterical eye symptoms, etc. 

The effect of anomalies of menstruation upon the healthy is usu- 
ally not considerable. Salo Cohn found that the consecutive narrow- 
ing of the field of vision was more marked than in normal menstru- 
ation. There were no differences dependent upon the different forms 
of disturbance of the menses. The narrowing of the visual field was 
all the more marked, the more jDronounced the molimina; it 
amounted to 10 and 15°, and often varied in its extent. When men- 
struation and molimina were wanting, the narrowing of the visual 
field was also absent. It is well known that pain alone may cause 
concentric narrowing of the field of vision amounting to complete 
blindness (things growing black before the eyes) ; this is generally 
followed by syncope unless the patient is in a recumbent posture. 
This is favored by loss of blood, and, according to Cohn, the narrow- 
ing of the visual field was most pronounced in profuse menstruation. 
Metrorrhagia may also give rise to amblyopia and amaurosis from 
loss of blood (page 290). In a girl of twenty years Abadie {Union 
Med., 1874, No. 15) observed that after the onset of menstruation, 
which was accompanied with violent epistaxis, complete blindness 
developed in both eyes. At a later period the ophthalmoscope showed 
atrophy and pigmentation of the optic nerve, findings which are 
characteristic of hemorrhage into the nerve or its sheaths. 

In amenorrhoea Mooren {I.e.) observed interstitial keratitis with 
monthly irritative conditions, although the menstrual flow did not 
appear. This influence was not felt in disseminated choroiditis and 
posterior sclero-choroiditis. Hence it may be inferred that the former 
disease was still active, while the two latter had run their course. 
Vicarious hemorrhages in and about the eye may also occur in amen- 
orrhoea. This category probably includes Leber's case {I.e., p. 818) 
of hemorrhage into the optic nerve in a girl who had not yet men- 
struated and suffered from malformation of the genitalia. 

Such conditions are observed oftener in dysmenorrhoea. In this 
affection there are often inflammatory changes in the uterus and sur- 
rounding parts, such as flexions, versions, etc. Mooren (" Fiinf Lus- 
tren ophth. Thaetigkeit," Wiesbaden, 1882) observed spasm of ac- 



DISEASES OF THE SEXUAL ORGANS. 317 

commodation, associated with disturbed menstruation, continuing- 
until the latter became regular. Blindness which developed before 
the beginning of the menstrual period was cured by Pechlinus by 
artificial production of the menses (Cohn, Z.c, p. 32). Mooren saw 
monthly relapses of a pannous keratitis, which ceased with the ap- 
pearance of the menses. Danthon reports the improvement of irido- 
choroiditis after the occurrence of menstruation. 

Serous iritis and disseminated choroiditis, which are so often 
associated with menstrual disorders at the period of puberty in an- 
aemic and chlorotic girls, probably owe their origin to the same cause. 
Schiess-Gemuseus (15 Jahresb., p. 37) observed the development of 
serous iritis when menstruation ceased ; with the recovery from the 
eye disease the menses returned. 

Sudden suppression of the menses may result in hemorrhages. 
Hemorrhages into the optic nerve or its sheaths are usually bilateral 
and may recover almost completely. If they are situated imme- 
diately behind the papilla, the symptoms of stasis, neuritis, retinal in- 
filtrations and the like may also be found. In addition, there may 
be hemorrhages into the retina, into the vitreous, hemorrhagic detach- 
ment of the retina, hemorrhages into the anterior chamber, the con- 
junctiva, or into any of the vascular parts of theej^e. Cerebral hem- 
orrhages into parts which are important to vision may also produce 
corresponding focal symptoms. McKay {Jahr. f. Aug., 1882, p. 
322) states that he has seen blepharospasm in sudden suppression of 
the menses. 

Corneal infiltrations, which were seen by Daguenet and Teillais 
under these circumstances, are probably an accidental finding. Bri- 
erre's unilateral hemiopia (Cohn, Z.c, p. 106) was probably due to a 
small hemorrhage into one optic nerve. 

In the main, hemorrhages are also found at the menopause. At 
this time we meet with hemorrhagic glaucoma which sometimes ex- 
hibits monthly exacerbations. Mooren states that in a case of this 
kind he cured the dysmenorrhoeal symptoms, pains in the back, etc., 
by a double iridectomy. 

Profuse uterine hemorrhages at the menopause may also give rise 
to amblyopia and amaurosis. 



318 THE EYE IN RELATION TO DISEASE. 

The remarks made concerning menstruation also hold good, in a 
measure, with regard to pregnancy, parturition and childbed. 

In pregnancy the eyelids, like other parts of the body, are often 
pigmented, sometimes in a very striking manner. A certain ten- 
dency to phlyctenular affections of the conjunctiva and cornea is often 
present in pregnancy, likewise (especially in the latter half of preg- 
nancy) a certain degree of general weakness of innervation, of accom- 
modative and muscular asthenopia. Hysterical symptoms, for ex- 
ample polyopia, may also develop and disappear later. Bloding 
(Cohn, Z.C., p. 123) mentions a case in which "strabismus, first of 
one eye, then of both eyes," was a sure indication of beginning preg- 
nancy ; this was evidently a case of spasm of convergence. Nieden 
{Mon. f. Aug., Oct., 1891) reports a case of a primipara, in whom 
epiphora had lasted since the third month and had been preceded 
by salivation and morning sickness; both lachrymal glands were 
somewhat swollen. Cocaine exercised a magical effect. 

The development of cataract during pregnancy must always be 
attributed to pre-existing disease, and serous iritis may be brought to 
pass. 

It is well known that albuminuria is frequent, especially in the 
second half of pregnancy, partly as the result of stasis and mechani- 
cal obstruction to the renal circulation, partly as the result of paren- 
chymatous nephritis. Albuminuric retinitis and ursemic amaurosis 
have been discussed on pages 300 and 308, and likewise unilateral and 
bilateral detachment of the retina, which is comparatively frequent 
in the former condition. All of these conditions often necessitate 
the induction of premature labor, although this does not always lead 
to recovery. Schoeler (Cohn, I.e., p. 138) reports the cases of two sis- 
ters, both of whom suffered during pregnancy from detachment of the 
retina without albuminuria or retinitis; temporary improvement oc- 
curred in one case. 

The majority of formerly reported cases of temporary amaurosis 
during pregnancy were probably ursemic amaurosis. Albuminuria 
and its eye symptoms are apt to relapse in subsequent pregnancies, 
and generally in a more severe form. 

Violent vomiting may result in conditions which resemble the 



DISEASES OF THE SEXUAL ORGANS. 319 

amblyopia and amaurosis after loss of blood {vide p. 290). To this 
category belongs Landesberg's case {Arch. f. Ophth., XXIV, 1, p. 
195) : impairment of vision until the patient was merely able to dis- 
cern light, with normal ophthalmoscopic appearances; recovery in 
four days. 

As a matter of course, all possible forms of eye disease may have 
been present prior to the pregnancy. This is true of Lotz's case 
{Mon. f. Aug., Sept., 1889) : temporary detachment of the retina as 
the result of albuminuria during pregnancy ; replacement of the retina, 
but persistent complete blindness after premature delivery. The 
woman had been myopic for a long time and had suffered from cho- 
rio-retinitis. 

Jaundice during pregnancy may give rise to temporary amauro- 
sis (Lutz, Diss. Tiibingen, 1882, two cases) ; at the autopsy on one 
case, " large globular structures were found to occlude some of the 
smaller vessels." 

The not infrequent improvement of diseases of all kinds, includ- 
ing eye diseases, after parturition must be attributed to the increased 
processes of absorption. 

According to Raehlmann and Witkowsky {Jahr. f. Aug., 1878, 
p. 132), mydriasis occurs with the beginning of labor pains, and is 
probably due to spasm of the sympathetic. Retinitis, but especially 
ursemic amaurosis and eclamptic attacks, may not occur until par- 
turition or even childbed. Very painful labors may give rise to at- 
tacks of sj^ncope, temporary blindness, or even traumatic hysteria. 
To this category belongs the case of Reuling {Jahr. f. Aug., 187?, p. 
41) : gradual double blindness without lesion shortly after deliver}-, 
finally complete restoration ; Matteson {ih., 1886, p. 309): complete 
blindness lasting four days; Weber {ih., 1873, p. 376) : almost com- 
plete blindness coming on six hours after very painful labor, without 
eclampsia or albuminuria ; recovery in a month. 

Hemorrhages during and after labor may cause amblyopia and 
amaurosis from loss of blood, and this is also true of hemorrhages dur- 
ing abortion. In the latter condition may be found diseases of the eye 
which are to be attributed to some general disease, such as syphilis, 
which has acted as the predisposing or exciting cause of the abortion. 



320 THE EYE IN RELATION TO DISEASE. 

Symptoms of temporary hysteria also occur during childbed. For 
example, Szili (Centr. f. Aug., June, 1882) reports sudden blindness 
on the fourth day after opening a window in a darkened room ; the 
reaction of the pupil to accommodation was retained, the ophthalmo- 
scopic appearances were negative; recovery in six weeks. 

Albuminuria and its sequelae are also frequent during childbed. 
Hemorrhages into all the vascular parts of the eye may occur in con- 
sequence, or they may be the result of non-septic emboli following 
venous thrombosis. Walter {Jahr. f. Aug., 1881, p. 90) observed 
embolism of the left central artery in phlegmasia alba dolens on the 
fourth day of childbed. To this category probably belong the ma- 
jority of hemorrhages into the retina, optic nerve, etc., which occur 
during childbed, apparently without cause, in the otherwise normal 
eye. The cases of neuritis (Leber, Pflueger) are possibly hemor- 
rhages into the optic nerve immediately behind the papilla, which 
have led to visible changes in the latter. As a matter of course cere- 
bral hemorrhages may also act as the cause of visual disorders in 
childbed. 

During parturition and childbed local and general septic infection 
is produced not infrequently by various inflammatory products. 
Metastases may thus develop in all organs, including the eye. In 
very acute sepsis from the absorption of a large amount of the chem- 
ical products of decomposition, and toward the end of life in the more 
chronic infections, extensive retinal hemorrhages are often found. 
Death occurs before they have undergone any noticeable changes. 
In less acute infection with organic inflammatory products, embolic 
suppurations (pysemia) are produced. In the eye, the choroid and 
retina are chiefly attacked, particularly the retina. The septic em- 
bolism is rapidly followed by suppuration which extends to the en- 
tire eye (panophthalmitis) and leads to its destruction. Whether the 
embolism occurred in the choroid or retina can only be determined 
by the ophthalmoscope at the very start; later this can only be de- 
cided by anatomical examination. Embolic panophthalmia is most 
frequent during the second and third weeks of childbed, and is not 
infrequently bilateral. Staphylococci, streptococci and bacteria have 
been found. The prognosis is usually bad both for the eye and life. 



DISEASES OF THE SEXUAL ORGANS. 321 

Recovery occurs occasionally, with the loss of one eye or both eyes 
(Hirschberg, Centr. f. Aug., 1885, p. 84; Cohn, I.e., p. 169). 

Abscesses have also been observed in the optic nerve (Michel, 
Arch. f. Ophth., XXIII, 2) and beneath the conjunctiva (Feuer, 
Centr. f. Aug., 1881, Feb.). 

As a matter of course the same conditions may develop when in- 
fection has taken place from an operation upon the female genitalia. 

Infection may also take place with germs which are less virulent 
than suppurative products. In this way we can explain the cases of 
iritis in childbed, reported by Galezowski, unless their development 
at that time was a mere coincidence. This is undoubtedly true of 
the cases of dacryo-cysto-blennorrhoea in childbed, which are de- 
scribed by this writer. 

Lactation is also mentioned as a cause of eye disease. It acts 
mainly as a debilitating factor. This is also true of repeated child- 
bed, especially if there have been profuse losses of blood. Under such 
circumstances we may find the most severe forms of general anaemia 
with their accompanying ocular symptoms. There may even be 
oedema of the lids, particularly the lower one, and extensive retinal 
hemorrhages. 

Phlyctenular diseases of the conjunctiva and cornea, particularlj" 
the severer forms of the latter, appear to me to be more frequent in 
nursing than in non-nursing women. Mastitis may develop from 
nursing infants who are suffering from blennorrhoea neonatorum 
(Legry, Prog. Med., 1887, No. 35). 

The new-born infant is exposed during parturition to direct and 

indirect injuries. Forceps delivery may be attended by contusions 

of the eye and lids, facial paralysis, ptosis, paralysis of the superior 

and external rectus (Bloch, Centr. f. Aug., 1891, p. 131; Berger, 

Arch. f. Aug., XVII, p. 191). These paralyses are due in part to 

direct injury by the forceps, as, for example, in facial paralysis or 

ptosis, in part to hemorrhages from the disturbance of circulation 

during delivery. Such hemorrhages occur in the lids, conjunctiva, 

orbit and, very often, in the retina and choroid. In the two latter 

cases they may possibly act as the cause of " congenital" disorders of 

vision, but they usually recover without leaving a trace (Naunoff, 
21 



322 THE EYE IN RELATION TO DISEASE. 

Arch. f. OpJith. , XXXVI, 3) . Hemorrhages into the orbit may give 
rise to exophthalmus, disturbance of vision and muscular paralyses 
(Philipsen, Aim. d^OcuL, Dec, 1891). In congenital paralyses, 
however, especially when the superior rectus and levator palpebrse 
superioris are involved, we must always think of congenital absence 
of these muscles. Atrophy of the optic nerve may result from for- 
ceps delivery (Beck, Jahr. f. Aug., 1889, p. 383), probably second- 
ary to hemorrhage into the nerve. 

Infection of the conjunctiva with gonorrhoeal secretion during 
parturition gives rise to blennorrhoea neonatorum. But even in severe 
forms the typical gonococci are sometimes absent, and, on the other 
hand, the latter are sometimes found in comparatively mild cases, so 
that the specific nature of the germ has been doubted. Other causes 
may produce clinically the same disease. 

Very many infections do not take place until after birth, and often 
the nurse, midwife, etc. , are the source of infection. I have seen 
little epidemics of blennorrhoea neonatorum in the clientele of certain 
midwives. This is true even of children who were born with un- 
ruptured membranes. In Taylor's case {Jahr. f. Aug., 1871, p. 220), 
the disease, which began on the third day, was unilateral. In Me- 
den's case {Mon. f. Aug., Oct., 1891), it developed at the end of 
twenty-four hours, was very mild, and the secretion contained no 
gonococci, although the four older children had suffered from blennor- 
rhoea neonatorum with gonococci, and the mother was suffering from 
vaginal blennorrhoea. It appears to me, however, to be very doubt- 
ful whether we are justified in assuming that the infection is due to 
injurious substances which are diffused into the foetal waters. 

Magnus {Mon. f. Aug., 1887, p. 389) observed a child who suf- 
fered from blennorrhoea neonatorum and secondary corneal disease at 
birth. Parturition had lasted three days and repeated examinations 
had been made, so that the infection was easily explained. 

Joint diseases after blennorrhoea neonatorum have been repeatedly 
observed (Darier, Jahr. f. Aug., 1879, p. 231; Deutschmann, Arch. 
f. Ophth., XXXVI, 1, p. 109). Darier also observed the develop- 
ment of purulent otitis media from the passage of blennorrhoeic pus 
into the ear, but this appears to be extremely rare. 



DISEASES OF THE SEXUAL ORGANS. 323 

The influence of diseases of the female organs upon visual disor- 
ders is usually overestimated. The real cause appears to consist of 
the various forms of anaemia, which have such a fruitful source in 
chronic female diseases. The pains, insomnia and more or less pro- 
fuse hemorrhages also play a part. We will return to this question 
later in discussing the results of severe anaemic conditions and con- 
stitutional anomalies. 

All sorts of hysterical symptoms, including Foerster's kopiopia 
hysterica, a form of ansesthesia dolorosa of the retina, diminished 
sensibility with photophobia, combined with general symptoms of 
weakness, may also occur in men. I have recently seen a number 
of excellent illustrations. The eye symptoms are so prominent and 
distressing because the patients cannot do any work. 

I do not believe that Mooren is justified in regarding neuro-retin- 
itis in retroflexion of the uterus and in ovarian tumors as a mere re- 
flex conveyed through the spinal cord. It is probably due in the 
majority of cases to a hemorrhage into the optic nerve immediately 
behind the papilla. As a matter of course, the anatomical proof of 
this statement can be furnished in very few cases. 

According toSwanzy {Jah7\ f. Aug., 1878, p. 264), iritis in girls 
of eleven to seventeen years is associated with uterine disease. It 
seems more probable to me that in such cases congenital syphilis is 
the cause of both diseases. 

Collins' (^6., 1886, p. 515) temporary blindness after Porro's oper- 
ation is probably to be regarded as traumatic hysteria. Similar con- 
ditions may be seen occasionally after other gynecological operations. 



OHAPTEE YIII. 

POISONS AND INFECTIOUS DISEASES. 

Although poisoning results from some chemical substances, and 
infection from a living morbific germ, nevertheless this distinction 
cannot always be carried out. There are numerous transitions and 
combinations, as we shall see in discussing ptomaine poisoning and 
sepsis. The results of chronic poisoning and of infectious disease 
are very similar. 

A. Poisons. 

We distinguish between acute and chronic poisoning. In the 
former, a large amount of the poison is received at one time ; in the 
latter, there is a constant reception of small doses, each of which may 
be unable to produce any symptoms. As a matter of course there 
are all possible transitions between these two extremes. 

Acute poisoning terminates fatally, or recovers, or it may result 
in a more or less chronic disease, even though recovery appeared to 
be complete. Thus, acute chloroform poisoning may prove fatal dur- 
ing the narcosis, it may pass off without doing any injury, or it may 
induce chronic parenchymatous changes, as, for example, in the re- 
nal epithelium and the walls of the vessels. 

An acute poisoning may produce direct symptoms in the eye, such 
as dilatation or contraction of the pupil, paralysis or spasm of accom- 
modation, visible changes in the fundus and its vessels (quinine, ani- 
line, nitrobenzol, carbonic acid), yellow vision, visual hallucinations 
and illusions, etc. Poisons which dilate or contract the pupils usu- 
ally have a corresponding effect on the vessels of the fundus oculi, 
but in many cases this is not pronounced. 

The eye symptoms often develop indirectly, as, for example, xe- 
rosis of the cornea and conjunctiva in the death agony, icterus which 



POISONS AND INFECTIOUS DISEASES. 325 

is often first seen on the conjunctiva, the development of cataract 
when there have been violent convulsions, retinal and other hemor- 
rhages from changes in the blood-vessels, etc. The kidneys are often 
affected, because very many poisons are excreted through these 
organs, and even the most acute hemorrhagic nephritis may result. 
This nephritis and the secondary chronic forms may also give rise 
to eye disease. 

Siibermann calls attention to the importance of thrombosis in 
many poisons, such as aniline, chlorate of potash and corrosive subli- 
mate, but this is stoutly denied by others (Falkenberg, Marchand, 
Virch. Arch., 123, 3, p. 567). 

Acute poisoning, especially with gases, such as sulphuretted hy- 
drogen and carbon sulphide, may induce traumatic hysteria. In 
poisoning with gases we often find conjunctivitis and hypersemia of 
the conjunctiva, and often more or less diminution of corneal sensi- 
bility'. Narcosis after all anaesthetics (ether, chloroform, nitrous ox- 
ide) may be followed by acute mania with delirium and other mental 
disturbances, later by dementia. According to Savage {Brit. Med. 
Journ., Dec. 3d, 1887), such effects may follow the action of all poi- 
sons and morbific germs which are capable of producing delirium 
(^.e., anaemia or hypersemia of the cerebral cortex). 

In chronic poisoning, direct eye symptoms are not frequent (myo- 
sis in chronic nicotine or morphine poisoning, mydriasis in chronic 
belladonna poisoning, etc.). Secondary eye symptoms, on the other 
hand, are frequent and result from vascular disease, interstitial or 
parenchymatous, chronic or acute hemorrhagic infiammations (polio- 
encephalitis acuta), partly in the eye itself, partly in the peripheral 
or central nervous system, and very often of the kidneys. Hemor- 
rhages and fatty degenerations in the fundus oculi, central and peri- 
pheral disorders of vision, pains, parsesthesise and anaesthesiae, 
spasms and paralyses may develop in this way. It is evident that 
vessel lesions will cause visible findings or clinical symptoms when 
they affect end-arteries — retina, cerebral cortex, kidneys. Certain 
poisons often exhibit a preference as regards localization. For ex- 
ample, arsenical paralysis begins in the lower limbs, lead paralysis 
in the upper limbs. 



326 THE EYE IN RELATION TO DISEASE. 

In the final cachectic stage there may also be general symptoms of 
exhaustion, such as anaemic asthenopia, slight nystagmus, hemera- 
lopia, etc. ; as a matter of course, the conjunctiva and eyelids also take 
part in general jaundice. A scorbutic condition may ensue in the 
last stage of alcoholismus. 

Chronic poisoning and its sequelae may be greatly aggravated by 
acute infectious disease, as, for example, toxic amblyopia by influ- 
enza. 

It is impossible to give a satisfactory chemical or clinical classifi- 
cation of poisons, because those which are chemically very different 
may produce very similar clinical symptoms (alcohol, tobacco, car- 
bon sulphide, lead) . I have, therefore, decided to adopt the unsci- 
entific but practical method of arranging them in alphabetical order. 

This article makes no pretence to completeness, but furnishes a. 
good general survey. 

Aconitine is a local mydriatic which is sometimes given inter- 
nally in certain neuralgias. Duigenam {Jahr. f. Aug., 1878, p. 
335), O'Brien, Stewart (ib., 1879, p. 229) and Hooper (^6., 1883) 
found mydriasis in aconite poisoning, but Glugge {ib., 1881, p. 292) 
mentions that it is not found constantly. O'Brien also noted twitch- 
ing of the lids in his case. 

^sculin. — Vide horse-chestnut. 

Alcohol poisoning is a very frequent cause of eye symptoms. 
After the first period of excitement, acute poisoning (drunkenness) 
shows paralytic symptoms (diplopia) which may pass into the most 
profound general narcosis with insensibility of the cornea and abo- 
lition of the reaction of the pupils to light. The ocular muscles may 
also take part in general convulsions. On the whole, however, eye 
symptoms do not play a prominent part in acute alcohol poisoning. 
Knapp {Arch. f. Aug. u. Ohr., V, p. 383) observed detachment of 
the retina in a myope, aged sixty-three years, who had taken a glass 
of brandy to relieve diarrhoea of several days' duration. 

The eye symptoms are more important in chronic alcoholism. It 
is well known that in this condition depressing factors (acute dis- 
eases, operations, injuries, etc.) may give rise to a usually temporary 
mental affection in which visual hallucinations and illusions are a 



POISONS AND INFECTIOUS DISEASES. 327 

prominent feature (delirium tremens) . At the same time there is 
regularly a marked concentric narrowing of the visual field which 
disappears in one or two weeks. This condition often develops spon- 
taneously, however, without any known exciting cause. As a rule, 
the ophthalmoscopic appearances are normal, unless complications 
are present. 

More importance attaches to the interstitial and parenchymatous 
changes and to diseases of the vessels as the result of chronic alco- 
holism. The lesions which develop in the brain, spinal cord, periph- 
eral nerves and kidneys are especially important as regards eye symp- 
toms. Among these the greatest prominence belongs to axial optic 
neuritis, incorrectly called toxic amblyopia. It begins with misty 
vision which gradually increases and is almost always present in both 
eyes, although vision is not alvvaj^s impaired uniforml}'. Central 
vision may be diminished to yV ot less. Careful examination shows 
that there is a central amblyopic spot in the field of vision, within 
which perception of red and green, in severe cases also of yellow 
and blue, is diminished or abolished. The external boundaries of the 
fields for white and colors are entirely or approximately normal. 
The disorder of vision and of color sense in the scotoma is character- 
istic of interference with conduction in the optic nerve. 

Ophthalmoscopic examination shows that the outer half of the 
papilla is pale "like dull porcelain," the inner half grayish-red, 
opaque, with obliterated borders and occasionally slightly swollen ; 
the calibre of the vessels is normal. Anatomically we have to deal 
with an interstitial inflammation, chiefly of the axial bundles of 
the optic nerve, which reaches its height near the optic foramen. 
The proliferation of the interstitial tissue with multiplication of the 
vessels, which exhibit increased fulness and sclerosis of the walls, 
subsequently leads to destruction of the medullary sheaths of the 
nerve fibres. Their axis cylinders remain intact for a while, but 
finally they may undergo complete atrophy. Centrally and periph- 
erally from the point of culmination the changes in the nerve appear 
to be purely atrophic. Uhthoff traced the ascending atrophy to the 
end of the optic tract, while the descending atrophj' is recognized by 
means of the ophthalmoscope. This shows an atrophic decoloration 



328 THE EYE IN RELATION TO DISEASE. 

of the outer half of the papilla where the macular fibres are 
collected. 

At the beginning of the affection the ophthalmoscopic appearances 
are sometimes negative, but they may also be very distinct where there 
is no disturbance of vision, especially in cases of recovery. 

It is often found that the patient sees better in twilight (nyctalo- 
pia), or that there are persistent colored after-images or subjective 
sensations of light (phosphenes) . This is probably due to irritation 
of the nerve fibres in the inflammatory focus. The misty vision may 
develop quite suddenly, and there are often striking changes from 
day to day. Other occasional disorders of vision, such as a sudden 
variation in the apparent size and distance of objects, monocular 
diplopia and polyopia (Daguenet, Ann. d'OcuL, 62, p. 136), remind 
us of hysterical affections and are not connected with the lesion of 
the optic nerve. They are probably due to irregularities of accom- 
modation. 

It is difficult to make very definite statements concerning the fre- 
quency of the disease. As a matter of course it is much more fre- 
quent in men. Among 1,000 cases of severe alcoholism Uhthoff 
found ophthalmoscopic changes 139 times (60 of these suffered from 
amblyopia) ; in 9 cases there was amblyopia without abnormal find- 
ings ; in 53 there was opacity of the papilla and surrounding parts, 
and in 6 cases marked congestion of the optic nerve. 

Strong and healthy individuals are rarely attacked. The major- 
ity suffer from gastric catarrh and are poorly nourished. There are 
also other signs of alcoholism, such as anorexia, morning vomiting, 
tremor of the limbs and tongue. The disease is most frequent in the 
later years of life when the power of resistance to injurious agencies 
is impaired. 

The prognosis is favorable if we can improve the general nutrition 
and secure abstinence from alcohol. Relapses are very common and 
are generally attended with still greater disturbance of vision, al- 
though complete atrophy of the nerve and blindness are rare. Injec- 
tions of strychnine are highly recommended in toxic amblyopias, 
although recovery would probably take place spontaneously. 

The disease is usually chronic. Cases with rapid onset of the 



POISONS AND INFECTIOUS DISEASES. 329 

inflammation and hemorrhages, such as Nettleship describes in to- 
bacco amblyopia, are extremely rare. Disorder of vision without a 
central scotoma is equally rare (Vossius, Mon. f. Aug., 1883, p. 291). 

The connection of this disease with chronic alcoholism has been 
denied by a number of writers, and it has been attributed to the coin- 
cident abuse of tobacco. Hutchinson (Ophth. Hosp. Rep., VIII, 
1) attributes all cases partly to tobacco, partly to adulterations of the 
alcoholic drink (for example, oil of absinthe) , and jSTettleship (Jahr. 
f. Aug., 1887, p. 257) states that he has never seen a case of pure 
alcohol amblyopia. On the other hand Millingen never observed 
toxic amblyopia among the Turks, who smoke but do not drink, and 
Fumagalli {JaJu\ f. Aug., 1874, p. 454) denies the occurrence of 
tobacco amblyopia. There can be no doubt that pure alcohol am- 
blyopia does occur and is all the more apt to develop, the stronger 
the alcoholic drink. Among beer drinkers it is very rare, among 
whiskey drinkers it is quite frequent. In the majority of cases the 
patients abuse tobacco as well as alcohol. In my opinion the former 
is more injurious than the latter. There are, however, pure cases of 
alcohol as well as tobacco amblyopia. 

There are clinical differences, although not of an absolute char- 
acter, between the two forms. Hirschberg {Deutsch. Zsclir. f. 
pract. Med., 1878, 17) states that in alcohol amblyopia the scotoma 
is central and always includes the point of fixation, while the tobacco 
scotoma is situated near, but not at the point of fixation (paracentral) . 
This may hold good of the majority of cases but is not always true. 
Alcohol amblyopia is said to be bilateral and to occur more suddenly ; 
the pupil is often wide and accommodation paretic. Tobacco ambly- 
opia is said to be often unilateral or at least very different in degree 
on the two sides ; the pupil is narrow (because nicotine is a myotic) 
and spasm of accommodation is frequent. The disorder of vision 
develops more gradually and is often progressive despite abstinence. 
[Muscular asthenopia is common with tobacco amblyopia. — Ed.] 

Similar inflammatory phenomena are often observed in other 
nerves (multiple alcoholic neuritis). The central nervous system 
is also attacked in many cases. Alcoholic forms of insanity are very 
frequent, while we rarely observe true focal symptoms, such as hemi- 



330 THE EYE IN RELATION TO DISEASE. 

anaesthesia, including the conjunctiva and cornea, central disorders 
of vision, hemiplegia. Paraplegia and paransesthesia also occur, 
and occasionally every possible systemic and focal disease of the 
brain and cord may be simulated (particularly tabes, by multiple 
neuritis of the sensory nerves) . 

In such cases the ophthalmoscopic findings may be of the highest 
diagnostic importance. Alcoholic pseudo-tabes is also unattended 
by myosis and reflex rigidity of the pupil, the girdle sensation, and 
disturbances of the bladder and rectum. Its development is more 
acute than in true tabes. 

Romiee {Bee. d^Ophth., 1881, p. 33) states that paresis of accom- 
modation is one of the first disorders of vision in alcoholism ; the 
pupil is more often dilated than narrow. Other paralyses of the ocu- 
lar muscles are only observed in combination with severe disease of 
the central nervous system and with the alcoholic mental disorders. 
Among 1,000 cases Uhthoff found inequality of the pupils in 25 cases, 
reflex rigidity of the pupil in 10 cases, and very slight reaction to 
light in 25 cases ; the reaction of convergence was almost always 
intact. In only 3 cases was there true muscular paralysis, each time 
a double abducens paralysis (possibly spasm of convergence). Two 
cases exhibited nystagmus, 13 cases nystagmus-like twitchings at 
the borders of the field of vision. 

Acute alcoholic paralysis of the eye muscles is due to hemorrhagic 
inflammation of the floor of the fourth ventricle. This begins sud- 
denly or within a few days, and is attended by headache, vomiting, 
pains in the limbs, ataxia, delirium, etc. Then there is more or less 
complete ophthalmoplegia externa with or without ptosis. Occasion- 
ally the internal muscles are also attacked. All but two cases of this 
" acute superior polio-encephalitis" occurred in hard drinkers, and a 
fatal termination ensued very rapidly. It is probable that similar 
hemorrhagic inflammatory processes in drunkards also occur in other 
parts of the central nervous system. 

The parenchymatous and interstitial renal lesions which develop 
in chronic alcoholism are often the cause of secondary changes in 
the eye. After long-continued alcoholism there may be a general 
tendency to hemorrhages (alcoholic scurvy). This may lead to hem- 



POISONS AND INFECTIOUS DISEASES. 33L 

orrhages into the conjunctiva, retina, optic nerve, brain, etc., as 
happens in other poisons, infectious and constitutional diseases. 

Among 500 insane alcoholics Uhthoff found 37 cases of xerosis of 
the conjunctiva in the shape of small, dull, rough, often frothy 
patches. The necrobiosis and fatty degeneration of the epithelial 
cells are evidently a part of the general impairment of nutrition; 
this is also true of the hemeralopia which is often noticed. 

Deneffe (Jahr. f. Aug., 1872, p. 373) observed sudden blindness 
(there was merely quantitative perception of light without any oph- 
thalmoscopic findings) in a formerly temperate individual who had 
been on a continuous debauch for a number of weeks. Vigorous an- 
tiphlogistic treatment resulted in rapid and complete recovery. On 
the other hand, Bruns observed marked impairment of vision (fingers 
could just be recognized at four feet) without corresponding ophthal- 
moscopic appearances in an individual who suddenly abstained, 
from drink. Strychnine injections produced a cure in six days. 

Amyl alcohol (fusel oil) is said by some writers to be the real 
cause of alcoholic amblyopia. 

Amyl nitrite causes dilatation of the retinal vessels and increased 
redness of the papilla, according to Aldridge {Jahr. f. Aug.., 1871, 
p. 322). This was not corroborated by others, despite the dilatation 
of the vessels of the face and violent throbbing of the carotids. Pick 
{Centr. f. d. med. Wiss., 1873, p. 865) observed, on looking at a. 
light wall, a round, yellow spot, surrounded by a bluish- violet zone, 
i.e., a subjective perception of the yellow spot and the visual purple. 
According to Schiff {''Jahr. f. Aug., 1871, p. 151) sensibility remains 
intact when the amyl is administered to animals, but the pupil does 
not react to sensory irritation. A favorable result from the inhala- 
tion of a few drops of amyl has been observed in several cases of toxic 
amblyopia, but especially in ischsemic conditions of the retina and 
optic nerve. [Such a result has been observed by myself in several 
instances ; once in a man who for almost twenty-four hours had blind- 
ness of both ej'es, in the beginning total, and at the time I saw him 
slightly less serious, permitting some perception of light. The retinal 
arteries were almost empty and the nerves pallid. Inhalation of ni- 
trite of amyl soon brought about the usual congestion of the face and 



332 THE EYE IN RELATION TO DISEASE. 

dizziness with improved sight, and in twenty minutes vision was 
fully restored and the ophthalmoscopic picture became normal. 
—Ed.] 

Aniline produces, according to Galezowski (Eec. d^ Ophth. , 1876, 
p. 210), a bluish-green color of the hair of workers in this dye, also 
vertigo, headache and nausea. In two cases it caused a photophobia, 
misty vision and ciliary injection ; in one case it gave rise to severe 
relapsing iritis, first of the right eye, and Hve or six months later of 
the left eye. The connection between these conditions is obscure. 
According to Leloir (Gaz. Med., 1879, p. 606) there is marked my- 
driasis in aniline poisoning. In Mueller's case, however, there was 
narrowing of the pupil (Deutsch. med. Woch., 1887, N'o. 2). In a 
case of poisoning with nitrobenzol which was adulterated with ani- 
line, Litten {Berl. kl. Woch., 1881, Nos. 1 and 2) found the pupils 
very small but still reacting, the conjunctiva of a violet color and 
with hemorrhages in the cul-de-sac. The fundus oculi was intensely 
red, the vessels looked as if filled with ink; there were also a few 
hemorrhages. Vision was unimpaired. In an aniline worker, aged 
forty-four years, MacKinlay (Ophth. Soc. of the United Kingdom, 
1886, p. 144) found a brownish color of the conjunctiva and cornea, 
and slight impairment of vision. The condition improved when the 
patient left the factory. 

Antifehrin produces dilatation of the retinal veins, according to 
Mueller, but this is denied by Herczel. After the administration of 
seven doses of 15 grains each within two and one-half hours, Simp- 
son observed merely narrow and immobile pupils; the other symp- 
toms were unimportant. 

Antipyrin may produce urticaria upon the lids. Berger {Jahr. 
f. Aug., 1889, p. 507) observed hypersecretion of tears; Guttmann 
{ibid., 1887, p. 256) observed amaurosis, lasting one minute, after a 
15-grain dose in a delicate woman of twenty-five years. 

Apomorphine gives rise, according to Bergmeister and Ludwig 
{ibid., 1885, p. 248), to complete anaesthesia of the cornea and con- 
junctiva within ten minutes after injection, and also produces corneal 
cloudiness and disagreeable general symptoms. 

Argentum Nitricum. — Vide Silver. 



POISONS AND INFECTIOUS DISEASES. 333 

Arsenic poisoning, when acute, resembles an attack of cholera. 
When chronic, four stages may be distinguished : 1, vomiting, 
diarrhoea and headache; 2, bronchial, nasal, conjunctival catarrh 
and cutaneous eruptions ; 3, sensory disorders ; 4, paralyses, especially 
of the legs. 

Prolonged administration of arsenic may give rise to herpes zoster 
(Hutchinson) . It is also said to be followed occasionally by a brown 
discoloration of the skin, which may be mistaken for Addison's dis- 
ease and disappear after the remedy is discontinued (Foerster, Berl. 
kl. Woch., 1890, No. 50). 

In young workers in artificial flowers, Kittel (Jahr. f. Aug., 1873, 
p. 240) noticed redness and scales upon the lids; in a few there were 
small ulcerations on the conjunctiva of the lower lid. 

Liebert (Mon. f. Aug., 1891, p. 181) observed retro-bulbar neu- 
ritis after the use of arsenic ; on both sides there was a distinct para- 
central scotoma for red and green with normal visual fields. The 
patient had taken arsenic for three and one-half years to relieve gen- 
eral psoriasis. The visual disorder developed two weeks after the 
dose was increased. 

Hoffmann {Jahr. f. Aug., 1889, p. 508) noticed slight nystagmus 
in chronic arsenic poisoning. According to Hutchinson {Ophth. Be- 
vieiv, Jan., 1889), prolonged administration of arsenic in skin disease 
may give rise to vitreous opacities which he attributes to a periph- 
eral retinitis. 

According to Sury-Bienz ( Viertelj. f. ger. Med. , Neue Folge, Bd. 
49, 2) , a brownish-red, later icteric color of the conjunctiva occurs in 
poisoning with arseniuretted hydrogen. 

Atropine is the most generally used mydriatic in ophthalmology, 
and hence the majority of poisonings follow its application to the 
eyes. It is said that the most acute symptoms of poisoning have 
followed the introduction of a single drop of the ordinary solution. 
The most striking symptom is the marked dilatation of the pupils, 
but this does not always take place to the maximum extent, even in 
fatal cases. 

The internal administration of atropine and belladonna also pro- 
duces hypersemia of the fundus and may even excite an attack of 



334 THE EYE IN RELATION TO DISEASE. 

glaucoma, while conjunctival catarrh and eczema of the lids^ some- 
times extending over the entire face to the neck, are found after the 
instillation of impure solutions in predisposed individuals. 

Visual hallucinations are sometimes prominent. They are espe- 
cially apt to occur in the dark, and are frequent in chronic poisoning. 
The latter is sometimes induced by prolonged instillation of atropine. 
The bitter taste, scratching in the throat and difficult deglutition 
which are constantly present in acute poisoning are usually wanting 
in the chronic form, while the hard pulse, congested face and diges- 
tive disturbances are prominent. 

Injections of morphine are the best antidote, while pilocarpine 
cannot be recommended so highly. 

Eeich {Centr. f. Aug., 1889, April) observed the daily occur- 
rence of epistaxis, which lasted about a quarter of an hour, five to 
ten minutes after the instillation of atropine for myopia; nothing ab- 
normal was found in the nose. A solution of duboisine had the same 
effect, but to a less marked degree. 

Tansley {Jalir. f. Aug., 1877, p. 116) observed mydriasis of the 
same side after the introduction of atropine into the auditory meatus 
and after the application of a belladonna plaster to one side of the 
chest. This was probably due to the accidental transmission of the 
drug to the eyes by the patient. 

Belladonna. — Vide Atropine. 

Botylismus. — Vide Ptomaine poisoning, p. 358. 

Bromide of potassium given internally not infrequently pro- 
duces conjunctivitis, sometimes with phlyctenular foci of inflamma- 
tion, even when a bromide eruption is not present on the rest of the 
body. In a patient who had taken 90. in twentj^-eight hours, Schweig 
(N. Y. Med. Bee, Dec. 30th, 1876) observed comatose sleep of four 
days' duration, lowered temperature, a feeble, accelerated pulse, su- 
perficial stertorous respiration, salivation, conjunctival catarrh and 
slight mydriasis lasting several days. In an epileptic lunatic of 
twenty-three years, who took 10.0-15.0 potassium bromide daily, 
Euebel (Jahr. f. Aug., 1884, p. 337) observed sudden blindness with 
a pale papilla and narrow vessels; recovery in five weeks after dis- 
continuing the remedy, and a relapse on its renewal. 



POISONS AND INFECTIOUS DISEASES. 335 

Caffein. — Vide Coffee. 

Calabar, — Vide Eserine. 

Calomel. — Vide Mercury. 

Cannabis Indica. — According to Ali {Rec. d^Ophth., 1876, p. 
258), hasheesh acts like tobacco except that it is more injurious and 
more often produces toxic amblyopia. This is often unilateral, as in 
the case of tobacco, and there is often merely a scotoma without color 
disturbance. It is well known that visual hallucinations are one of 
the chief symptoms of a hasheesh debauch. 

According to Oliver {Jahr. f. Aug., 1883, p. 302), sight is veiled; 
there is disturbance of accommodation with normal or narrow pupils. 
Suesskind {Wuertemb. aerztl. Corr.-Bl., 1887, No. 31) and Casiccia 
{Jahr. f. Aug., 1883, p. 302) also saw mydriasis after poisoning with 
cannabis. 

Werner {ibid., 1886, p. 255) observed violet vision (which always 
precedes the yellow vision of santonin poisoning !) and a mist before 
the eyes, after a 0.04 dose of the extract in a small and nervous 
woman. 

Carbolic JLcid.— Falkson {Arcli. f. kl. Chir., XXVI, p. 204) 
states that in poisoning with carbolic acid the pupils are usually nar- 
row, rarely dilated, and that they react sluggishly. Silk {Jahr. f. 
Aug., 1881, p. 291) saw narrow pupils during profound coma in a 
fatal case. Xieden {Berl. kl. Woch., 1882, No. 49) observed amau- 
rosis, lasting twenty hours, with normal ophthalmoscopic appearances 
and dilated pupils. But as this was a case of irrigation of an empy- 
ema cavity, followed at once by collapse with great weakness and 
nausea, it is questionable whether the eye symptoms were due to car- 
bolic-acid poisoning. 

Carbonic-oxide poisoning is the type of a severe poisoning 
with gases; coal gas and illuminating gas are its most frequent 
sources. 

In the acute initial stage the eyes are not affected, and there is 
very little that is characteristic in the eye symptoms during recovery. 
In one case Ball {Jahr. f. Aug., 1878, p. 253) observed a paradoxical 
reaction of the pupil during the poisoning, i.e., the pupil dilated on 
the entrance of light and contracted in the dark. 



336 THE EYE IN RELATION TO DISEASE. 

In fatal cases fatty degeneration is found in the liver, spleen, kid- 
neys, muscles, etc. Within the skull there is marked congestion, 
which is absent only at the very start or after the process has lasted 
a long time ; later there are numerous capillary hemorrhages, more 
rarely larger hemorrhages, especially in the basal ganglia. This re- 
sults later in red and yellow softening. These changes are due to 
fatty degeneration of the cerebral arteries. Similar changes may 
also be found in the spinal cord and peripheral nerves. This ex- 
plains the various affections of the brain (Illing, Wien. med. 
Zeitschr., 1874, No. 23: homonymous hemianopsia) and spinal 
cord, the sensory and motor paralyses, the neuroses, temporary 
diabetes, etc., which are observed as sequelae of carbonic-oxide 
poisoning. 

The ophthalmoplegias, which have been observed in a number 
of cases and which almost always terminate in more or less complete 
recovery, are due to hemorrhagic processes in the nerve nuclei or in 
the peripheral nerves; Knapp {Arch, f, ^wg., IX, 2, p. 229), paraly- 
sis of all the ocular muscles, partial recovery in two months; Em- 
mert {Corresp.-Blatt f. Schweiz. Aerzte, 1890, p. 42), central paraly- 
sis of the left motor oculi and some of the branches of the trigemi- 
nus and facial ; almost complete recovery. 

Herpes zoster has also been noted as a sequel in a number of cases » 
If the first branch of the trigeminus is implicated, the eye may also 
be implicated (Sattler, Jah7\ f. Aug.^ 1889, p. 555). This case is not 
perfectly clear because the anterior part of the eye contained mycotic 
thrombi, evidently starting from the cornea. (Attention must be 
called, however, to the fact that various writers regard herpes zoster 
in general as infectious.) It is a noteworthy fact that only those 
fibres which started from the Gasserian ganglion, not those which 
passed through the ganglion, were degenerated. The former could 
be traced to the ciliary ganglion. 

Retinal hemorrhages are rarely mentioned (Becker, Jahr. f. Aug. , 
1889, p. 511; associated with venous congestion of the fundus), al- 
though they would undoubtedly have been found in many cases if a 
search had been instituted. 

Carbonic-acid accumulation in the blood causes mydriasis, ac- 



POISONS AND INFECTIOUS DISEASES. 337 

cording to Schiff, as the result of sympathetic irritation. The oph- 
thalmoscope shows a characteristic dark, sometimes almost black, 
color of the columns of blood in the vessels, particularly the veins. 
If the cause consists of obstruction to respiration or circulation, hem- 
orrhages are frequent. They are produced mechanically. The pupil 
is often contracted. 

Chloral, when given in narcotic doses, produces marked myosis, 
during which there is abolition of the reflex dilatation of the pupil 
after sensory irritation ; mydriasis is said to occur after very large 
doses or prolonged administration. Hence, myosis is generally pres- 
ent in chloral poisoning. The ophthalmoscopic appearances are neg- 
ative. 

After a variable length of time cutaneous eruptions and conjunc- 
tivitis are observed, and may necessitate discontinuance of the rem- 
edy; urticaria of the lids also occurs. 

Disturbances of vision occur in rare cases. Kirkpatrick {Jahr. 
f. Aug., 1873, p. 214) observed temporary blindness in addition to 
severe nervous seizures. Mandeville {ibid., 1872, p. 458) reports, 
in addition to considerable conjunctival irritation, diplopia of several 
days' duration. In a woman, who suffered twice from marked im- 
pairment of vision after a dose of chloral, he claims to have observed 
an exudative irido-choroiditis, which was finally cured by iridectomy. 
Two months later a relapse developed after another dose of chloral. 
Was not the irido-choroiditis already present? Patruban {Wien. 
med. Presse, 1875, p. 1,046) mentions a panophthalmitis after poi- 
soning with chloral. 

Chlorate of potash may cause ursemic amaurosis through the 
intense hemorrhagic nephritis which large doses will produce. 

Chloroform. — Opinions differ in regard to the condition of the 
pupils during the administration of chloroform. During narcosis 
the pupils are narrow as in sleep ; if the narcosis is not very profound, 
the pupils dilate after cutaneous irritation or on calling loudly. The 
pupils are usually dilated during the stage of excitement prior to 
narcosis proper. According to Budin (Gaz. des Hop., 1874, p. 910), 
vomiting may also produce mydriasis, but Schiff {Jahr. f. Aug. , 
1874, p. 150) contradicts this in part, in view of his experiments on 



338 THE EYE IN RELATION TO DISEASE. 

dogs. It is evident, however, that the conditions in animals are 
often different from those in men. 

Dilatation of the pupil during narcosis indicates the necessity for 
caution; sudden marked mydriasis is an evidence of impending 
asphj^xia. 

Vogel {Jahr. f. Aug., 1879, p. 82) assumes three different ways 
in which the pupil acts during chloroform narcosis: 1. Contraction 
during deep narcosis, dilatation on sudden waking. 2. The opposite 
condition. 3. The pupil is moderately narrow and does not react. 

According to Warner {ib., 1877, p. 217) the ocular movements 
become disassociated in chloroform narcosis, but do not in ether nar- 
cosis. 

Repeated use of chloroform — occasionally, perhaps, a single ad- 
ministration — may result in fatty parenchymatous degenerations of 
various organs, which may not produce clinical symptoms until a 
much later period. 

Schirmer {Mon. f. Aug., 1871, p. 246) reports a detachment of 
the retina which, according to the statement of the myopic patient, 
developed during narcosis (struggles of vomiting?). Mathewson 
{Jahr. f. Aug., 1876, p. 238) mentions an apoplectic attack, which 
developed fifteen minutes after an iridectomy under chloroform, in 
an individual with general atheroma of the vessels. As a matter 
of course the vomiting and choking of narcosis may prove an excit- 
ing cause for hemorrhages in any organ. 

In an individual who had drunk chloroform, Niemann (Berl. kl. 
Woch. 1887, No. 1) observed myosis followed by mydriasis. 

Chromic Acid. — Yellow vision has been observed in several cases 
in which sweating feet were treated with a five-per-cent solution of 
chromic acid {Deutsch. Militaeraerztl. Zschr., 1890, p. 239). 

Chrysarohin ointment when rubbed into the skin is said to pro- 
duce conjunctivitis. According to Trousseau {Jahr. f. Aug., 1886, 
p. 331), it develops in a few hours, is almost always bilateral, and is 
free from secretion, while conjunctivitis which is due to the direct 
entrance of chrysarobin into the conjunctival sac is usuall}' unilateral 
and attended by profuse secretion. These statements are in part 
disputed by others, and it is by no means certain that all the con- 



POISONS AND INFECTIOUS DISEASES. 339 

junctival attacks do not result from direct inoculation. In rare 
cases, corneal ulcers have been observed. 

Cocaine may produce symptoms of poisoning, even after the sub- 
cutaneous injection of 0.004, and several cases are reported in vrhich 
its introduction into the conjunctival sac produced general symptoms 
(Meyerhausen, Wien. med. Presse, 1885, No. 22; Burchard, Char- 
ite-Annal., XIII, p. 653). 

Maximum mydriasis appears in acute poisoning, but the cornea, 
according to Bettelheim, is very sensitive to touch. [This statement 
is of dubious value. Its probable explanation is that corneal insen- 
sibility had disappeared while mydriasis remained. — Ed.] Liq. 
ammon. anisat. is said to act favorably as an antidote. 

In chronic poisoning visual hallucinations play a prominent part. 
Diplopia, amblyopia, dancing of objects, colored vision, micropsia, 
etc., are observed occasionally. 

Attacks of glaucoma following instillation of cocaine solution 
have been observed in a number of instances (Chisolm, Maier, Javal, 
Manz). Marckwort (Arch. /. Aug., 1887, p. 452) also observed acute 
glaucoma after the protracted application of cocaine to the nasal 
mucous membrane. 

Coffee. — Caffeine is a feeble mydriatic and is also said to be 
anaesthetic in a measure. Hutchinson (Centralbl. f. Aug., 1887, 
p. 240) claims to have seen a caffeine amblyopia which closely re- 
sembled quinine amblyopia. 

Coniine. — Hugo Schulz [Deutsch. med. Woch., 1887, No. 23) 
found that inhalations of coniine gave rise to violent headache, in- 
creased heart's action, profuse perspiration, epiphora, insomnia, men- 
tal confusion, inability to keep the eyes open and burning of the 
conjunctiva (hypersemia). 

Creosote. — Vide Iodoform (Hutchinson's case). 

Curare, when given internally, causes myosis, but at a very late 
period. 

Cyanide of Potassium. — During the stage of asphyxia of potas- 
sium-cyanide poisoning, Mueller- Warneck (Ber^l. kl. Woch., 1878, 
No. 5) observed prominence of the eyeballs and enormous dilatation 
of the pupils, which were completely irresponsive. Souwers (Jahr. 



340 THE EYE IN RELATION TO DISEASE. 

/. Aug. J 1878, p. 235) attributes a swelling of the upper lids and 
sluggishness of the pupils, which he observed in a photographer, to 
his frequent use of potassium cyanide. 

De Tatham {ib., 1884, p. 337) claims to have observed temporary 
hemiopia (lasting a few hours) from inhalation of the vapor of dilute 
prussic acid. 

Cytisin (cytisus laburnum) gave rise in one case to vomiting, 
small pulse, cold sweat, dilated pupils, pale optic nerve and narrow 
retinal vessels, symptoms similar to those of ergotin poisoning 
(Albutt, Jahr. f. Aug., 1872, p. 344). 

Daturine is said, by the majority of writers, to be identical with 
atropine ; according to Ladenburg, it is identical with hyoscyamine. 

Digitalis. — In a man of fifty-seven years, who was poisoned with 
90.0 tincture digitalis, Jeanton {Gaz. des Hop., 1885, No. 56) ob- 
served mydriasis and cloudy vision, on the second day yellow vision ; 
recovery in a week. In a fatal case Hauber {Muench. med. Wocli. , 
1890, 1^0. 42) observed marked myosis which continued after death. 

Duboisine is said to produce general symptoms more readily than 
atropine; they are identical with those of the latter drug. Symp- 
toms of poisoning after dropping into the eye are reported by Carl 
(Mon. f. Aug., 1879, p. 339), Chadwick [Centr. f. Aug., 1887, p. 
155), Jacubowitsch {Jahr. f. Aug., 1884, p. 334). Like atropine it 
may also excite attacks of glaucoma. 

Ergotin and other preparations of ergot cause contraction of the 
smooth muscular fibres, especially of the blood-vessels, and may thus 
lead to necrosis of the tissues. The narrowing of the vessels and the 
pallor of the papilla may be visible with the ophthalmoscope. Tem- 
porary disorders of vision are due directly to spasm of the vessels in 
the eye, possibly also in the brain. The pupils are usually somewhat 
iilated and react sluggishly. 

The general vascular spasm may also result in hemorrhages. 
Davidson (Jahr. f. Aug., 1883, p. 303) observed hsematemesis, 
hsematuria, hemorrhages into the lids and lips, etc. It is probable 
that such accidents occur in individuals with diseased vessels and 
poor general nutrition. 

Cataract, which is usually double, develops not infrequently within 



POISONS AND INFECTIOUS DISEASES. 341 

a few years after ergotin poisoning which is evidently in causal rela- 
tion with it. The hardness or softness of the cataract, its rapid or slow 
advance correspond to the patient's age. Tepljaschin {Jahr. f. Aug. , 
1891, p. 275) reported twenty-seven cases of this kind after an epi- 
demic in the winter of 1879-80, in which the convulsive, not the 
gangrenous, form of ergotism had appeared. The cause is to be re- 
garded as nutritive disturbances in the lens, owing to spasm of the 
vessels of the ciliary body and also of the other vessels of the interior 
of the eye. 

Iritis after ergot poisoning in an epidemic in Upper Hessen, 
which was reported by Menche (Deutsch. Arch. f. kl. Med., 
XXXIII), appears to be very doubtful in its etiolog3^ Hulme {Ame7\ 
Med. News, Nov. 5th, 1887) observed swelling of the face, dilatation 
of the pupils and indistinct vision after an injection of an ounce of 
the fluid extract of ergot. 

Erytliropliloein is one of a series of remedies which, when ap- 
plied locally, produces anaesthesia of the cornea and conjunctiva, but 
is impracticable on account of the violent irritation and even inflam- 
mation to which it gives rise. 

Eseriiie. — Although eserine is the most generally employed 
myotic, distinct myosis is not always present in poisoning with 
preparations of calabar. Indeed, pronounced dilatation and abol- 
ished reaction of the pupil have been mentioned in a number of 
cases (Leibholz, Viertelj. f. ge7\ Med., 1892, p. 284). Instillation 
of the solution into the conjunctival sac is the most frequent 
cause of poisoning. Among the symptoms of the latter, Carreras 
Arago {Jahr. f. Aug., 1874, p. 265) observed temporary complete 
blindness. 

Ether. — Among 1,200 ether inhalations, Jacob {Jahrh. f. Aug., 
1879, p. 229) observed mydriasis in six cases. Warner {ih., 1877, p. 
217) mentions difference in the ocular movements during ether and 
chloroform narcosis. If this were constant it would prove that the 
ether narcosis was not very profound. 

Ethyl Chloride. — In dogs, Dubois (Arch, de Physiol., XX, 7 
8) observed long-continued dense corneal opacities, due solely to 
oedema. 



342 THE EYE IN RELATION TO DISEASE. 

Ethyl diamin has been found among the ptomaines. It causes; 
mydriasis, which is often present in ptomaine poisoning. 

Ethyl Bichloride. — Dubois and Roux (Compt. Bend., 1869, No. 
266) observed, during and after ansesthesia, an acute attack of glau- 
coma with pronounced opacity of the cornea, but with slight external 
signs of inflammation. 

Ethyl Nitrite. — Hill {Lancet, Nov., 1878) observed dilatation and 
immobility of the pupil in a case of poisoning in a child of three years. 

Filix Mas. — A number of cases of blindness have been observed 
after the use of large doses of this remedy. Eich {Deutsch. med. 
Woch., 1891, No. 32) collated three fatal cases, one under his own. 
observation, which ran the course of a strychnine poisoning, witk 
narrow pupils. 

Double amaurosis is most frequent (rarely there is amblyopia) ,. 
without findings; the pupils are dilated and exhibit no reaction. 
This pupillary symptom may also be present when there is no dis- 
turbance of vision. Immermann {Corresp.-Blatt f. Schweiz. 
Aerzte, July 1st, 1887) saw double atrophy of the optic nerve, Fritz 
{Cent. f. Aug., 1887, p. 278) unilateral atrophy with permanent 
blindness, develop out of the double amaurosis without findings. 
This proves the peripheral nature of the visual disorder which is. 
evidently similar to that occurring in quinine poisoning. In one 
case, Schlier {Muench. med. Woch., 1890, No. 32) found albuminuria, 
so that a sort of ureemic amaurosis might be suspected, but such a 
condition is extremely improbable. 

Fish and Meat Poisoning. — Vide Ptomaines. 

Fungus poisoning may produce various eye symptoms, accord- 
ing to the nature of the fungus. The active substances which they 
contain vary greatly, even in the same variety of fungus. Those 
which contain muscarine produce spasm of accommodation and myo- 
sis {vide Muscarine) ; others, especially morchella, produce mydriasis 
(Baj'er, Aerztl. Intell.-Bl., 1881, No. 1). In still others (agaricus 
phalloides, Handford, Jahr. f. Aug., 1887, p. 250) the pupils are 
unaffected. In the last-mentioned case there was also amblyopia — 
possibly spasm or paralysis of accommodation — and at the autopsy 
punctate hemorrhages of the serous membranes and marked fatty 



POISONS AND INFECTIOUS DISEASES. 343 

degeneration of the liver were found. Hence it is not surprising that 
hemorrhages and fatty degenerations have been found occasionally 
in the retina. There will be visual disturbance in case of delirium 
and hallucinations. 

Fusel Oil. — Vide Amyl alcohol. 

Gelsemium when taken internally dilates the pupils, according 
to Fronmueller and Ott. According to Ringer and Murell, the 
pupils are contracted and mydriasis is only produced when the drug 
is dropped into the conjunctival sac. But the statements are also at 
variance with regard to the action of the remedy under the latter 
circumstances, so that the action upon the eye probably depends upon 
accidental mixture with other substances. 

Hasheesh. — Vide Cannabis indica. 

Homatropine may produce general symptoms similar to those of 
atropine, when dropped into the conjunctival sac. Harlan {Mon. f. 
Aug., 1891 p. 189) observed slight attacks of glaucoma after its use. 
Cheney (Bost. Med. and Surg. Journ., Jan. 23d, 1890) reports "hys- 
terical" mydriasis, paralysis of accommodation and blindness from 
the use of h3''drobromate of atropine. De Schweinitz and Hare 
{Amer. Med. Neics, Dec. 24th, 188?) claim to have seen diminished 
frequency of the pulse as one of the symptoms. 

Horse Chestnut {JEsculus hippo castaneum). — In a boy of three 
and one-half j'ears who was poisoned by the green rind of the horse 
chestnut, Salomon {Brit. Med. Journ, Dec. 19th, 1887) noted great 
dilatation of the pupils and distressing visions, in addition to con- 
gestion of the face, a full pulse and drowsiness. 

Hydracetin. — Gruenthal {Centr. f. Aug., 1890, p. 73) observed 
small retinal hemorrhages after inunctions with hydracetin ointment ; 
the urine contained a good deal of albumin. 

Hyoscine and Hyoscy amine. — In poisoning with these two 
mydriatics the more or less marked dilatation of the pupils may 
possess diagnostic importance. 

Hluminating Gas. — Vide Carbonic oxide. 

Iodine and Iodide of Potassium. — Epiphora and pains in the 
eyes, sometimes passing into fully developed catarrhal conjunctivitis, 
belong to the typical history of iodism. The eyelids take part in the 



344 THE EYE IN RELATION TO DISEASE. 

not infrequent temporary oedemas of the skin, and may also be in- 
volved in iodine eruptions (acne, etc.). In four cases of acute iodism, 
Ehrmann {Wien. med. Blaett.^ 1890, ISTo. 44) noted the occurrence of 
trigeminal neuralgia in addition to the symptoms just mentioned. 
Quinine effected rapid recovery. The fact that all the patients suf- 
fered from syphilis may not be devoid of importance, for the reason 
that under such conditions neuralgias may occur independently of 
iodism. According to Ehrmann, the latter acts as an exciting cause 
by inducing hyperaemic swelling of the nerve sheaths. 

It is well known that when potassium iodide is taken internally, 
the dusting of calomel into the conjunctival sac is apt to produce 
erosions, probably from the development of iodide of mercury 
^Schlaefke, Jahr. f. Aug., 1879, p. 216). I have never observed this 
accident, despite repeated experiments. It must also be remembered 
that calomel alone, if not very finely powdered, may produce erosions 
of the conjunctiva. 

Meurer (Arch. /. Aug., XXII, p. 24) even claims that he has 
seen erosions of the conjunctiva due to the external application of 
potassium iodide ointment and the coincident application of white 
precipitate ointment to the conjunctival sac. 

Iodoform. — According to Kuester {Berl. kl. Woch., 1882, No. 
14), the pupils are contracted in iodoform poisoning. In a girl of 
sixteen years, upon whom iodoform applications were made during 
the after-treatment of a resection of the hip joint, Hirschberg ob- 
served typical toxic amblyopia (fingers at two to three metres with 
central scotoma) with normal fundus and dilated pupils. During 
the protracted internal administration of iodoform (combined with 
creosote in pills) Hutchinson {Jahr.f. Aug., 1886, p. 254) also ob- 
served typical toxic amblyopia with corresponding ophthalmoscopic 
appearances. Recovery after injections of strychnine and discontin- 
uance of the pills. 

Trousseau {ib., 1887, p. 419) ) reports that a few hours after dust- 
ing iodoform upon a syphilitic ulcer of the upper lid, an erysipelatoid 
swelling appeared upon the entire half of the face, and was attended 
by the development of vesicles; this healed as soon as the remedy was 
discontinued. It reappeared when the iodoform was again applied. 



POISONS AND INFECTIOUS DISEASES. 345 

Lead poisoning, when acute, resembles an attack of cholera and 
has no characteristic eye symptoms. In chronic lead poisoning, on 
the other hand, central and peripheral affections of sight are frequent. 
The remarks made concerning chronic poisoning in general also 
hold good here. The principal part is evidently played by changes 
in the walls of the vessels, particularly sclerosis and periarteritis, 
and these are often visible with the ophthalmoscope {vide p. 293). 
Spots of softening, ependymitis, internal hydrocephalus and hemor- 
rhages in all possible localities of the brain are secondary in charac- 
ter. There are manifold disturbances both visual and motor. 

The ophthalmoscope often shows a unilateral or bilateral neuritis, 
either of the alcoholic form (p. 327) with corresponding disturbance 
of sight, or as a diffusely reddened and cloudy papilla without nota- 
ble swelling and sometimes with hemorrhages. In the latter event 
the impairment of sight may proceed to complete blindness, and may 
terminate in more or less atrophy of the optic nerve. A white sheath 
around the arteries and corresponding changes in the vessels are often 
visible. Retrobulbar neuritis, impairment of sight or even blindness 
w^ithout findings, but terminating later in atrophy of the optic nerve, 
are also observed. 

The central disorders (due mainly to periarteritic changes, par- 
ticularly in the cerebral cortex) include visual hallucinations, opti- 
cal and other aphasias, hemianopsia with and without reaction of the 
pupils to light, etc. Concentric narrowing of the field of vision, 
color disorders and other hysteria-like symptoms are also observed 
occasionally. The clinical symptoms of tabes, multiple sclerosis, etc., 
sometimes develop. 

There may also be disorders of movement, either central (as- 
sociated disorders of movement, nystagmus), or nuclear and periphe- 
ral. Galezowski {Jahr. f. Aug., 1877, p. 382) describes paralysis of 
accommodation; Landesberg (ibid., 1880, p. 215) a unilateral pa- 
ralysis of the abducens and also of the entire motor oculi, probably as 
the result of multiple neuritis. Ptosis is also mentioned several 
times. 

A frequent sequel of chronic lead poisoning is disease of the kid- 
ney with albuminuria, and the latter may give rise to disorders of 



346 THE EYE IN RELATION TO DISEASE. 

sight. The ophthalmoscopic appearances of albuminuric neuro-reti- 
nitis may occur although there is no albumin in the urine. 

So-called lead amblyopia and amaurosis, ^.e., impairment of sight 
without findings, which were formerly diagnosed very often, hardly 
ever come into question at the present time. Either objective find- 
ings are demonstrable after a certain lapse of time, for example, atro- 
phy after retrobulbar neuritis, or the disorder of sight is of such a 
character (hemianopsia or ursemic impairment) that it permits a defi- 
nite diagnosis even without visible findings. Temporary lead amau- 
rosis is almost always ursemic. 

Although recovery from every possible form of disorder of sight 
and movement is quite frequent — only those cases are directly unfa- 
vorable which are attended with considerable atrophy of the optic 
nerve and are the results of renal disease — still it is well to give a 
cautious prognosis in the individual case, inasmuch as we usually 
have to deal with advanced stages of poisoning. 

In the treatment of corneal ulcers with lead wash, the cornea is 
apt to become incrusted with lead. Bellouard {Jahr. f. Aug., 1882, 
p. 363) has seen this develop spontaneously in individuals who suf- 
fered from ulceration of the cornea and were exposed in factories to 
dust containing lead. 

Marsh gas is said by Eeuss {Arch. f. Aug., XXIII, 3, p. 252) to 
be the cause of the nystagmus of miners. 

Menthol, in doses of 5.0 to 7.0, killed rabbits in five to ten min- 
utes. Opacity of the lens developed immediately after death, but 
this could not be produced during life (Charrin and Roger, Centr. /. 
Aug., 1888, p. 60). 

Mercury and its salts, despite their frequent administration, 
rarely give rise to eye symptoms. The acute poisoning very closely 
resembles phosphorus poisoning, and also gives rise to similar eye 
symptoms, particularly retinal hemorrhages and fatty degenerations. 
During the treatment of itch with inunctions of blue ointment. Dyes 
(Deutsche Klinik, 1871, No. 11) observed temporary blindness 
which was relieved in a few days by internal and external treatment 
with sulphur. Kaemmerer {Virch. Arch., 59, p. 467) and Alsberg 
(Jahr. f. Aug., 1880, p. 228) demonstrated the presence of mercury 



POISONS AND INFECTIOUS DISEASES. 347 

in the urine of individuals into whose conjunctival sacs calomel had 
been dusted for some time. Kohn (Bee. d'Ophth., 1875, p. 365) 
observed violent attacks of colic at night in a child of three years 
whenever calomel was employed in this way. 

There are also no characteristic eye symptoms in acute mercurial 
poisoning, while the results of chronic poisoning resemble those of 
chronic lead poisoning. 

Methyl Alcohol. — Poisoning with this substance produced blind- 
ness within twenty-four hours, according to Mengin (Rec. d'Ophth., 
1879, p. 663). 

diethyl chloride produces myosis in the first stage of narcosis, 
mydriasis in the second stage. Sudden contraction indicates danger 
of suffocation (Panhoff, Jahr. /. Aug., 1882, p. 123). 

Morphine. — In chronic morphine poisoning in the dog, Laborde 
{Jahr. /. Aug., 1877, p. 217) found the fundus congested during the 
stage of vascular excitement, and pale and anaemic during narcosis. 
At the end of two weeks the latter condition became permanent. 
Ocular sj^mptoms are also mentioned in a number of cases of mor- 
phine poisoning in man. Apart from contraction of the pupils, which 
possesses great diagnostic importance, Wagner {Mon. f. Aug., X, 
p. 335) observed complete double blindness in a patient who had 
taken 2.0 morphine sabcutaneously within five days. The papillae 
were slightly cloudy, the arteries very narrow. The case was then 
lost to observation. Schiess-Gemuseus reports the case of a man 
who, after taking a sleeping-powder, slept for thirty-six hours and 
then suffered marked impairment of sight and hearing. At the end 
of three weeks he found right hemianopsia, and on the left side slight 
concentric narrowing of the field of vision. As in toxic amblyopias, 
the papilla was reddened on the inner side, pale on the outer side. 
Among other symptoms Schreiber {Jahr. f. Aug., 1888, p. 539) ob- 
served aphasia, agraphia and alexia after acute morphine poisoning. 

Although morphine is a powerful myotic, Levinstein {Berl. M. 
Woch., 1876, No. 14) observed mydriasis as often as myosis in mor- 
phine habitues. The mydriasis which Tupper {Jahr. f. Aug., 1879, 
p. 229) observed, associated with spasm of the eye muscles, after an 
injection of morphine, was either due to pressure upon the eye or 



348 THE EYE IN RELATION TO DISEASE. 

must be interpreted as mydriasis following irritation of the 
skin. 

Jaeger's case {ib., 1870, p. 380) proves that a non-aseptic injection 
of morphine into the temples may give rise to an orbital phlegmon, 
followed by exophthalmus, blindness and, later, by atrophy of the 
optic nerve. 

Muscarine^ the poisonous alkaloid of certain mushrooms, first pro- 
duces maximum spasm of accommodation (in some individuals this 
is the sole symptom) and then myosis. This is noteworthy for the 
reason that ptomaine poisoning often shows the symptoms of musca- 
rine. Indeed, the latter appears to occur as a ptomaine and has been 
isolated by Schmiedeberg from neurine, which is an undoubted 
ptomaine. 

Mussel Poison. — Vide Ptomaines. 

Naphthalin. — Bouchard {Bev. Clin. d'OcuL, 1886, No. 7) found 
that 1.0 naphthalin per kilogramme in rabbits, when given daily, 
produced cataract in three to twenty days. Prior to the development 
of the cataract the vitreous usually contains numerous floating crys- 
tals (oxalate, sulphate and carbonate of lime, according to Panas) 
and there are large white patches (oedema) in the retina. At a later 
period these patches become retracted in the centre, atrophy and ad- 
here to the retina {vide Panas, Dor, Hess, Magnus, in Centr. f. 
Aug., 1887, pp. 104, 145, 295, 300). According to Kolinski {Arch, 
f. OpMh., XXXV, 2, p. 29) , the changes in the lens and retina appear 
to be due to hemorrhages into the ciliary body, ciliary processes and 
choroid. Such conditions have not been found in man after the use 
of naphthalin. 

Nicotine. — Vide Tobacco. 

Nitrohenzol poisoning gives rise, among other symptoms, to 
marked venous congestion of the fundus; the blood is often strik- 
ingly dark. In a case of this kind in a workman in a roburite fac- 
tory, Nieden {Cent. f. Aug., 1888, p. 193) observed diminution of 
vision to yV with concentric narrowing of the field, which gradually 
disappeared. In one eye a retinal hemorrhage, as large as the disc, 
was found. 

Nitrous oxide gives rise, according to Aldridge (Jahr. f. Aug. , 



POISONS AND INFECTIOUS DISEASES. 349 

1871, p. 322) to dilatation of the retinal arteries and increased redness 
of the papilla. Bordier {ib.^ 1876, p. 295) observed extreme contrac- 
tion of the pupils in a comatose condition an hour after the extraction 
of a tooth ; in a few hours the condition had become normal. Nar- 
cosis with nitrous oxide is said to be attended by agreeable visual 
hallucinations. 

Op u«??i produces, according toLoring, no visible vascular changes 
in the fundus. Myosis is never absent in acute poisoning and rarely 
absent after prolonged administration. Hammerle {Deutsch. Med. 
Woch., 1888, p. 838) reports impairment of vision in acute poison- 
ing. A patient suffering from lead colic took 15.0 laudanum in one 
night ; repeated vomiting. On the following morning, great oppres- 
sion, cj^anosis, maximum myosis and, during the course of the morn- 
ing, impairment of vision proceeding to complete blindness. Recov- 
ery in two days. Hammerle assumes that the blindness was due to 
arterial spasm, but the case is not a pure one, inasmuch as the pa- 
tient was suffering from lead poisoning, and, in addition, similar 
conditions have been seen after vomiting alone. 

Galezowski (Bee. d^Ophth., 1876, p. 210) reports, in two cases of 
chronic opium poisoning, cloudy vision, metamorphopsia, rapid ex- 
haustion of the eyes, impairment of central vision and slight color 
disturbance with normal boundaries of the visual field and normal 
ophthalmoscopic appearances. In one case 1,000.0 opium had been 
taken within fifteen months; in the other the patient had taken 20.0 
daily for forty years for the relief of facial neuralgia. 

The corneal softening observed several times by Paster (Muench. 
Med. Woch., 1886, No. 6) in opium smokers is a part of the general 
marasmus and is a bad omen as regards life. [I saw suppuration 
and destruction of each cornea in a Jewess, aged about sixty, who 
had undergone the most extreme marasmus from opium-eating dur- 
ing many years. Her skin was a mahogany brown, shrivelled and 
leathery, and emaciation extreme. ^ — Ed.] 

Oxalic Acid. — In experimental oxalic acid poisoning of rabbits, 
Koch (Diss. Dorpat., 1879) noted dilatation of the pupils, followed 
by contraction (symptom of pain). 

Petroleum- ether poisoning gave rise in one case (Schmidfs 



350 THE EYE IN RELATION TO DISEASE. 

Jahrb., 1891, 1, p. 34) to great dilatation and loss of reaction of the 
pupils and nystagmus ; recovery. 

Phenol. — Vide Carbolic acid. 

Phosphorus poisoning produces eye symptoms which are similar 
to those found in carbonic-oxide poisoning. Retinal hemorrhages 
may appear before anatomical changes can be demonstrated in the 
vessels (Niederhauser, Diss. Zurich, 1875), At a later period fatty 
degeneration develops, chiefly in the capillaries and arteries, but also 
in larger or smaller foci in the retinal tissue. These may be visible 
with the ophthalndoscope and produce a picture similar to that of re- 
tinitis albuminurica. Hemorrhages into the optic nerve, brain, etc., 
may also produce eye symptoms. 

As a matter of course the conjunctiva takes part in the jaundice 
which soon develops. 

Physostigmine. — Vide Eserine. 

Picjnc Acid. — After a dose of 0.3 internally, Hilbert (Centr. f. 
Aug., 1885, March) noticed yellow vision lasting about an hour, and 
not followed by blue or violet vision. On account of the smallness 
of the dose this could not have been due to a yellow coloration of the 
media, and hence the yellow vision must have been the result of di- 
rect central irritation ( ?) . 

Pilocarpine when dropped into the eye acts as a powerful myo- 
tic ; when given internally the myosis is slight and indeed mydriasis 
has been often observed. After internal administration, increased 
secretion from the lachrymal gland is often noticed, and this may 
even follow simple instillation into the conjunctival sac. In five 
cases Landesberg {Mon. f. Aug., 1882, p. 51) observed rapid progress 
of cataract after pilocarpine or jaborandi treatment. On account of 
the powerful influence of the injections upon the general organism, 
temporary amblyopia may occasionally result (Fuhrmann, Wien. 
med. Woch., 1890, No. 34). 

Piscidium. — Seifert {Berl. kl. Woch., 1883, No. 29) occasionally 
observed mydriasis after the prolonged use of ext. piscidii as an hyp- 
notic. 

Podophyllin. — The workmen who are engaged in grinding the 
root of podophyllum suffer from traumatic conjunctivitis and cutane- 



POISONS AND INFECTIOUS DISEASES. 351 

ous inflammations unless properly protected. Ulceration of the cor- 
nea is an occasional sequel. According to Hutchinson (Jahr. f. 
Aug., 1872, p. 263), the dust does not produce the irritation at once, 
but only on the following day. 

Prussic Acid. — Vide Potassium cyanide. 

Quinine. — Several dozen cases of visual disorder as the result of 
large doses of quinine have been reported. Almost all of them oc- 
curred in individuals whose nutrition had been notably impaired. 
Unilateral or bilateral impairment of vision, which may even pass 
into blindness, occurs more or less suddenly ; seldom slowly. After 
a time recovery takes place or permanent disorders which correspond 
to partial atrophy of the optic nerve remain, viz. , central impair- 
ment of sight, concentric narrowing of the visual field, defects of the 
visual field with or without color disturbance. Hemeralopia may 
also be left over (Kohn, Rec. d'Ophth., 1874, p. 384). 

The ophthalmoscope shows a pale or perfectly white disc and nar- 
row vessels, occasionally slight retinal exudation. When the latter 
affects the macula, it shows a cherry-red spot as in embolism (Gruen- 
ing, Buller). Similar ophthalmoscopic appearances are obtained ex- 
perimentally in animals after the administration of large doses of 
quinine. 

Barabaschew (Arch. f. Aug., XXIII, 2) has experimented on 
men with doses of 2.4-3.6. He produced: 1. Acute gastritis with 
temporary increase of central vision. 2. Pallor of the face, vertigo, 
syncope, somnolence, tinnitus aurium, transient myosis passing into 
moderate mydriasis. 3. Considerable narrowing of the retinal arte- 
ries and pallor of the papilla, acceleration followed by slowing of the 
pulse. 4. Concentric narrowing of the visual field. 5. Impairment 
of vision passing even into temporary blindness. The latter was ob- 
sered in only one case (lasting half a minute, but recurring ten times 
at intervals of ten to fifteen minutes). There was no corneal anaes- 
thesia or color-blindness, which have been observed in several cases. 
In one case he found transient cloudiness of the retina. 

The temporary dimness of vision is caused by the arterial spasm. 
In case of poor nutrition, ischsemia gives rise to necrobiotic changes 
in the optic nerve, as in amblyopia and amaurosis after loss of blood, 



352 THE EYE IN RELATION TO DISEASE. 

ending in partial or total atrophy with permanent impairment of 
vision and narrow retinal arteries. According to De Schweinitz 
(Centr. f. Aug., 1891, p. 118) thrombosis also occurs. The changes 
which he mentions in the cortical centres of vision perhaps depend 
merely upon imperfect hardening. The visual disturbances in 
quinine poisoning have a decidedly peripheral character. 

Favre {Jahr. f. Aug., 1873, p. 114) reports the case of a man, 
aged thirty- seven years, who exhibited color disturbances, with no 
injury to vision, after typhus fever and prolonged treatment with 
quinine. Some doubt has been thrown upon this case. 

Tiffany is the only one who mentions diminution of intraocular 
pressure. [For a very complete summary of cases see Atkinson 
{Journal of American Med. Assoc, Sept. 28th, 1889). He found 
cases reported as early as 1841, De Schweinitz (Trans. Am. Ophth. 
Soc, 1891, p. 23) gives the appearances during life and the patholog- 
ical examination in dogs to whom large doses had been given.] 

Resorcin. — Hirschberg {Cent. f. Aug., 1886, Dec.) observed con- 
junctivitis develop after the application of a ten-per-cent resorcin 
ointment to the face. 

Salicylate of soda gives rise, in rare cases, to symptoms similar 
to those produced by quinine. After a dose of 8.0 which was taken 
within nine hours, Galli {Jahr. f. Aug., 1880, p. 145) observed com- 
plete blindness, lasting twenty -four hours, in a vigorous peasant girl 
of sixteen years ; there was marked mydriasis. The ophthalmoscopic 
appearances were normal and the urine did not contain albumin. 
After 2.0 doses every two hours, Gibson and Telkin {Jahr. f. Aug., 
1889, p. 223) found, at the end of eight hours, extreme myosis with 
loss of the reaction of the pupils to light. These symptoms disap- 
peared thirty hours after the remedy was discontinued. 

After a dose of 4.0 Rosenberg {Deutsch. med. Woch., 1886, 
No, 33) noticed violent burning of the skin, oedema of the lids and 
a bluish-red macular eruption. After another 7.0 had been taken, 
large vesicles formed upon some of the maculae and the conjunctiva 
became reddened and swollen. This affection was perhaps related 
to an urticaria ab ingestis. 

Santonin. — The characteristic feature of santonin poisoning is 



POISONS AND INFECTIOUS DISEASES. 353 

yellow vision. This begins ten to fifteen minutes after the adminis- 
tration of the drug, and, on careful observation, is always found to 
be preceded by transient violet vision. The spectrum is first con- 
tracted on the violet side, and then, but to a less extent, on the red 
side ; it is evident that the rays in question are no longer perceived 
by the retina. In my own case the color is an orange yellow passing 
into green. 

The yellow vision sometimes occurs paroxj^smally, especially on 
looking at white and brilliant objects, while it is very little no- 
ticed in the background of a moderately light room. All shadows 
appear in the complementary color, viz. , violet. At the same time 
the patient sometimes sees flashes and sparks of light. Unless com- 
plications are present, central vision, the fundus and the pupils are 
normal. The field is not noticeably contracted, but adaptation in the 
dark is very much delayed (page 29). 

There is evidently a peripheral insensibility of the retina to violet 
and a part of the red rays, preceded by temporary hypersensibility to 
these rays (violet vision) . Corresponding to this process I observed 
in myself a temporary feeling of warmth and burning of the entire 
integument, followed by a prolonged and striking sensation of numb- 
ness, i.e., hypersesthesia and parsesthesia following an hyperses- 
thesia. 

The fact that, despite the insensibility to violet light, the shadows 
are seen in the complementary violet, proves that the central color 
sense is undisturbed, that the condition is solely a peripheral non- 
irritability to the extreme rays of the spectrum (Rose, Virch. Arch. , 
16, 18, 19, 20, 28; Knies, Arch. f. Aug., XVIII, p. 61; Koenig, 
Cent. f. Aug., 1889, Jan.). If small doses are administered for a 
considerable time, there will be insensibility to violet, but yellow 
vision will not be produced (Henneberg, Jahr. f. Aug, 1889, p. 509). 

Severe santonin poisoning is attended not infrequently with cere- 
bral symptoms, such as spasms, headache, speech disorders (aphasia), 
conjugate deviation, etc. ; mydriasis may also be produced, some- 
times unequally in both eyes. (Van Rey, Ther. Monatsh., Nov., 
1889). 

Saponin.— 'Kq^^Iqv {Ber^l. kl. Woch., 1878, No. 32) states that he 
23 



354 THE EYE IN RELATION TO DISEASE. 

observed in his own case severe pains, strabismus and exophthalmus 
of the left eye, as the symptoms of acute saponin poisoning. 

Secale Cornutum. — Vide Ergotin. 

Silver. — The eyelids and conjunctiva take part in the general 
pigmentation which appears after the excessively prolonged internal 
administration of silver. The conjunctiva is much less affected than 
in some cases in which nitrate of silver is applied locally. 

Snake Virus produces an acute hemorrhagic diathesis, but the 
effect varies with, the different varieties of snakes. The disorders of 
sight and of ocular movements may be due to central or peripheral 
hemorrhages. If they affect the optic nerve, permanent impairment 
of vision with partial or total atrophy may develop. According to 
Laurengao (Jahr. f. Aug., 1875, p. 376), temporary and permanent 
amblyopia and blindness after snake-bites are not rare. 

Sti^ychnine. — This alkaloid, which is employed so extensively in 
amblyopias, produces no eye symptoms, or at least very slight ones, 
in cases of poisoning. No special action on the pupil is noticeable 
despite the intense irritation of the vasomotor centres. 

Acute strychnine poisoning may give rise to acute nephritis. 
According to Honigmann {Deutsch. med. Woch., May 30th, 1889), 
tliis is probably due to stasis from arterial spasm. It is therefore 
possible that the effects of albuminuria might become evident in the 
eye. 

Sulfonal. — In sulfonal poisoning Dillingham {Jahr. f. Aug., 
1890, p. 451) noticed ptosis which lasted two weeks, and Knaggs {ih.) 
reports anaesthesia of the conjunctiva and of other parts of the 
body. 

Sulphide of carbon has given rise, particularly in india-rubber 
workers, to an entire series of acute and chronic poisonings with im- 
plication of the organ of sight. 

In acute poisoning a stage of excitement is followed by collapse, 
often attended with motor and sensory disturbances (the cornea is 
often insensible), diminished reflexes, etc. These are followed not 
infrequently by impairment of vision, with or without color disturb- 
ance, concentric narrowing of the field and of the color boundaries, 
monocular polyopia, macropsia and micropsia, hemiansesthesia, par- 



POISONS AND INFECTIOUS DISEASES. 355 

aesthesija, local anaesthesia, paralyses and spasms, occasionally hem- 
eralopia, etc. These symptoms must be interpreted in part as hys- 
terical (toxic hysteria) ; in fact they are the result of peripheral 
neuritis. 

In chronic poisoning the chief eye symptom is toxic amblyopia, 
axial neuritis of the optic nerve. This is similar to alcoholic ambly- 
opia, and is manifested by a central scotoma with color disturbance 
and corresponding ophthalmoscopic appearances. The latter may 
also be normal or color disturbance may be wanting ; nyctalopia oc- 
curs occasionally. The eye symptoms are usually preceded for a 
considerable period by general nervous symptoms, such as headache, 
muscular weakness, etc. With very few exceptions the affection 
of the optic nerve recovers completely under proper care. The sensi- 
bility of the cornea and conjunctiva is slightly diminished, as in 
many chronic poisonings with gases (Gallemaerts, Ann. d' Ocul. , 90, 
p. 154; Pierre Marie, Neurol Centr., Feb. 15th, 1889; Maass, Diss. 
Berlin, 1889). 

Sulphur Chloride. — This substance, which is used in the caout- 
chouc industry, appears to produce toxic amblyopia. Nettleship 
{Jahr. f. Aug., 1884, p. 334) observed amblyopia and nervous de- 
pression ; Frost reports amblyopia, neuritis and atrophy of the optic 
nerve in india-rubber workers who handled carbon bisulphide and 
chlorine bisulphide. 

Sulphur pomade (vaselin 100.0, wax 5.0, sulphur 10.0, oil of roses 
one drop) is said to have produced symptoms of poisoning after hav- 
ing been used for eight years (Eichbaum, Berl. kl. Woch., 1887, 
'No. 42). Among the symptoms were large and rigid pupils which 
did not react to light or cutaneous irritation (atropine?). 

Sulphuretted Hydrogen. — In a case of poisoning with this gas 
Brouardel {Jahr. f. Aug., 1885, p. 266) observed mydriasis, exoph- 
thalmus, insensibility of the cornea and disappearance of the corneal 
reflexes. 

Sulphuric Acid. — One of the few cases of acute superior polio-en- 
cephalitis (page 178) was the result of sulphuric-acid poisoning; aU 
the rest, with one exception, occurred in hard drinkers. 

Sulphuric Ether. — Vide Ether. 



356 THE EYE IN RELATION TO DISEASE. 

Tea.— Wolfe {Jahr. f. Aug., 1879, p. 230) attributes a case of 
liquefaction of the vitreous, with numerous floating opacities, to ex- 
cessive tea-drinking, but the connection between the two is very- 
doubtful. 

Tobacco. — The toxic amblyopia which occurs during the chronic 
abuse of tobacco has already been discussed under the heading of 
alcohol. It was there stated that tobacco amblyopia is more often 
unilateral than alcoholic amblyopia, or is at least very different in 
degree on the two sides, that there is usually myosis and often spasm 
of accommodation, that the impairment of vision develops more 
gradually and, despite abstinence, increases more frequently. Law- 
ford {Centr. f. Aug., 1890, Sept.) reported nine cases in which typi- 
cal tobacco amblyopia terminated in complete atrophy of the optic 
nerve, a very rare event in alcoholic amblyopia. Mention has also 
been made of the difference in the position of the scotoma, in alcoho- 
hol (pericentral), in tobacco (paracentral), but this difference is by 
no means constant. While the majority of writers consider tobacco 
much more dangerous than alcohol as regards the development of 
toxic amblopyia (many even deny the potency of alcohol as a causal 
factor), Fumagalli {Jahr. f. Aug., 1874, p^ 454) denies the occurrence 
of a tobacco amblyopia. 

Acute inflammatory symptoms in the fundus are rare. Nettleship 
(Ophth. Hosp. Rep., XI, p. 370) reports two cases of retinal hemor- 
rhages, one associated with neuritis. Ponti {Annal. di Ott., Ill, p. 
107) observed a true neuritis. Although the disease of the optic 
nerve from abuse of tobacco is usually severe, corresponding 
affections of other nerves, paralyses, etc., are rare events. 
Fontan (Rec. d' Ophth., 1883, p. 309) reports, in a very excessive 
smoker, a sudden double paralysis of the motor oculi, but with 
narrow pupils, which recovered slowly after abstinence from 
tobacco. Although the possibility of tobacco paralysis of the 
ocular muscles cannot be denied, their great rarity should lead to 
caution in assuming a direct connection between the two in indi- 
vidual cases. 

Tobacco amblyopia rarely develops in a strong, youthful individ- 
ual. It develops either at an advanced age, when the resistance to 



POISONS AND INFECTIOUS DISEASES. 357 

external agents has diminished, or when the general nutrition has 
been impaired by anorexia, chronic gastric catarrh, etc. 

Complete abstinence from smoking is usually secured more easily 
than partial abstinence. In view of the laxative action of tobacco, 
care should be taken during the period of abstinence to secure reg- 
ular evacuations from the bowels, preferably by means of Carlsbad 
water or salt. 

Simons and Valzah (Jahr. f. Aug., 1877, p. 216) found pro- 
nounced myosis in cases of acute nicotine poisoning, corresponding 
to the myotic action of nicotine, while Kosminski (ib., 1871, p. 345) 
reports dilatation of the pupil in a servant who, in order to relieve 
toothache, had inserted tobacco in the hollow tooth. This case 
hardly appears to be one of poisoning, but, in view of the visual im- 
pairment and concentric narrowing of the field of vision, reminds us 
decidedly of traumatic hysteria. This is probably also true of 
O'Neill's case {ib., 1879, p. 229) of mydriasis in poisoning from the 
external application of tobacco. After an enema of tobacco, Wilkin- 
son (lb., 1889, p. 510) observed vomiting, diarrhoea and blindness 
lasting a quarter of an hour; the latter was possibly due to the 
vomiting. [In detecting tobacco amblyopia allowance must be made 
for the better appreciation of red at a distance of 3° to 5° from the 
macula than directly at the visual centre. This difference is slight, 
but is normal to many persons. As yet no measure of this normal 
difference has been established. That tobacco alone can cause cen- 
tral optic neuritis is an undeniable fact of clinical experience, yet the 
diagnosis founded on pallor of the infero-temporal quadrant of the 
optic disc must be taken with great caution; unless supplemented by 
scotoma for red and more or less amblyopia, judgment should be 
held in suspense. Furthermore, this local pallor may be wanting in 
genuine cases. For valuable knowledge on this topic see Uhthoff in 
Graefe's ArcUv, Bd. XXXII, Abth. lY, 95-188, 1886; and Bd. 
XXXIII, Abth. I, 257-318, 1887. A most convincing case in clini- 
cal experience is reported by Filehne in Graefe^s Archiv, Bd. XXXI, 
Abth. II, p. 27, 1885, as personal to himself. See also Groenow, 
Graefe's Archiv, Bd. XXXVIII, Abth. I, p. 1.— Ed.] 

It is not astonishing that workers in cigar factories, in which the 



358 THE EYE IN RELATION TO DISEASE. 

air is filled with the irritating dust, should suffer from conjunctivitis 
and photophobia (Bierbaum, Viertelj. f. ger. Med., 1889, SuppL, p. 
115). 

Despite its incompleteness, this resume of the eye symptoms of 
poisonings will give an idea of the manner in which the organ of 
vision, in the widest sense, can be implicated. Poisoning with 
ptomaines, meat, fish, ice-cream, toxalbumin, etc., constitutes a tran- 
sition to the infectious diseases proper. 

Ptomaines and toxalbumin which are poisonous to man are to 
be found in living animals, for example, in certain poisonous mus- 
sels and fishes. Often these are only poisonous at certain times or 
under certain conditions, and indeed the toxic character may belong 
only to special organs (liver, sexual glands). This was true of the 
cases of mussel poisoning at Wilhelmshafen a few years ago, which 
ran the course of acute alkaloid poisoning ; no micro-organisms could 
be discovered. 

Ordinary ptomaine poisoning is due to toxic substances which are 
produced by microbes from articles of food, although there may not 
be any decided phenomena of decomposition. The virus produced in 
this way may alone be absorbed, or the bacteria are absorbed, in- 
crease in the body, and there produce toxic products for a longer or 
shorter period, or both conditions prevail. In the first event we have 
to deal with an acute poisoning, not infrequently with an eruption 
of erythema and urticaria. It develops whenever the microbes can- 
not develop any further in the human body, or when they have been 
destroyed by the process of cooking, etc. In the second event, a 
more or less acute infectious disease develops, sometimes resembling 
cholera, sometimes resembling typhoid fever. In the third event the 
acute poisoning is followed by the acute infectious disease. 

There is not always a single definite microbe or toxic substance in 
these cases, and there may even be a number of microbes in the 
same case. The toxic products of disassimilation also vary in char- 
acter, and the chemical constitution of some has been accurately de- 
termined. Certain ones have a specific effect upon the eye. Mus- 
carine and neurine produce spasm of accommodation and myosis, 
tj^rotoxine causes paral^^sis of accommodation and mydriasis,, a very 



POISONS AND INFECTIOUS DISEASES. 359 

frequent symptom of meat poisoning. Other substances produce no 
special eye symptoms but are very similar to well-known poisons, 
such as curare, strychnia, atropia, etc. Scratching and dryness in 
the throat, difficulty in deglutition, gastritis and gastro-enteritis, 
dysuria, etc., are common symptoms of poisoning. 

As a general thing vision is not impaired, but a number of cases 
of amblyopia without findings have been mentioned. They gener- 
ally improve rapidly, but maj^ also remain permanent. A sufficient 
explanation of these cases is yet wanting. 

Apart from the very frequent injection of the conjunctiva, acute 
ptomaine poisoning is accompanied most frequently by paresis or 
paralysis of accommodation, generally with, more rarely without 
mydriasis, which is always bilateral. In very mild cases this may 
be the sole symptom. Thus, I observed slight paresis of accommo- 
dation, lasting twenty-four hours, in two individuals who had very 
probably been poisoned by an apparently innocuous fish [Jalir. f. 
Aug., 1886, p. 258). Such cases probably occur very often, but, as 
a matter of course, are easily overlooked. Paresis or paralysis of 
accommodation, usually with mydriasis, much more rarely the latter 
alone, are among the typical symptoms of poisoning by bad meat, 
although they are often absent (Cohn, Arch. f. Aug., IX, 2, p. 148; 
Leber, Arch. f. Ophth., XXVI, 2, p. 236; Ulrich, Jfo?i./. Aug., 1882, 
p. 230; Roth, Federschmidt, Jahr. f. Aug., 1883, p. 303; Virchow, 
Berl M. Woch., 1885, No. 48). 

Among other paralytic symjDtoms ptosis is the most frequent 
(Puerkhauser, Jahr. f. Aug., 1877, p. 219; Fleury, ib., 1885, p. 269; 
Hirschfeld, ib., p. 266; Kaatzer, Deutsch. med. Woch., 1881, No. 
7). Every other possible form of paralysis of the ocular muscles is 
also occasionally observed. They are generally nuclear in character 
(hemorrhages?), or are perhaps due to basilar neuritis, for example, 
complete or partial paralj'sis of the motor oculi (Fleury, I.e.), some- 
times bilateral parah'sis, with or without implication of other eye 
muscles (Eichenberg, Jalir. f. Aug., 1880, p. 247; Alexander, 
Centr. f. Aug., 1888, p. 87), double external ophthalmoplegia (Gutt- 
mann, Berl. kl. Woch., 1891, No. 8), etc. Although the symptoms 
are usually alike when due to the same cause, and only differ quan- 



360 THE EYE IN RELATION TO DISEASE. 

titatively, according to the amount ingested, nevertheless a symptom 
may be present or absent in the same "epidemic," although we can 
offer no sufficient explanation. 

In such poisonings there is either rapid recovery or death, or a 
transition into the second form, usually a typical infectious disease 
with a period of incubation lasting several days. Clinically and ana- 
tomically (swelling and ulceration of Peyer's patches) the condition 
exhibits a great resemblance to ordinary typhoid fever. This second 
form of ptomaine poisoning does not produce eye symptoms, but we 
occasionally observe all those visual symptoms which may occur in 
acute infectious diseases. 

B. Infectious Diseases. 

Infectious diseases are toxaemias which develop in a peculiar 
manner. The poison is produced by animal or vegetable parasites, 
but is rarely absorbed at the start in large quantities (septicaemia) . 
As a general thing the organized parasite is received in small quan- 
tities, proliferates within the body, and it is only after a certain 
length of time that its products of disassimilation cause symptoms of 
poisoning, in other words, the infectious disease. This is preceded 
by a stage of latency or incubation, which varies in duration from a 
few hours to several weeks or even years. Its duration varies ac- 
cording to the nature of the disease, but there may. be considerable 
variations even in the same disease. The outbreak of the character- 
istic symptoms is preceded by a longer or shorter prodromal period. 
This presents great similarity in the different infectious diseases, but 
may also exhibit characteristic features. 

It was plausible to assume that particular excitants of inflamma- 
tion always produced definite clinical infectious diseases, but experi- 
ence shows that this is not always true. Very few infectious dis- 
eases (splenic fever, glanders, tetanus, recurrent and typhoid fevers) 
possess a single micro-organism which occurs only in that disease 
and always produces the corresponding clinical history. In other 
cases a disease which is clinically the same may be produced by dif- 
ferent microbes, for example, pyaemia, erysipelas, purulent menin- 
gitis. Indeed, a single bacterium, for example, the diplococcus pneu- 



POISONS AND INFECTIOUS DISEASES. 361 

monise, may produce, according to circumstances, groups of sj^mptoms 
which are clinically distinct. Moreover, infection by a number of 
excitants is very common, either during the course of the disease or 
from the very start. This is facilitated whenever the infectious dis- 
ease has given rise to losses of substance or ulcerative processes in 
the integument, in the digestive, respiratory, or genito-urinary tract. 
A number of complications and sequelae are due to these secondary or 
mixed infections. It is especially the ubiquitous staphylococcus pyo- 
genes aureus and albus, streptococcus pyogenes, diplococcus pneumo- 
niae, and a few others, which produce similar complications, partic- 
ularly purulent processes and abscesses, in the most varied infectious 
diseases. 

In many infectious diseases a causal micro-organism has not yet 
been demonstrated, although the disease can hardly be explained 
except on the theory of living infection (small-pox, measles, scar- 
latina, etc.). 

At first there was a tendency to exaggerate the part played by 
specific microbes. The fact that many individuals are unsusceptible, 
even when infected, proves the great importance of the living nutri- 
ent substance. On the other hand there may also be an abnormal 
susceptibility to certain infectious diseases, as in one of my acquain- 
tances who, despite the fact that he had had small-pox and had twice 
been vaccinated successfully, was again attacked by small-pox shortly 
afterward and died. In making cultures it is found that the viru- 
lence of the germs may be increased or entirely extinguished, accord- 
ing to the character of the nutrient. An individual may also be in- 
susceptible from the start to the most virulent infectious substances. 
Probably this is due to certain chemical substances (products of dis- 
assimilation of the micro-organism?) which are present in one indi- 
vidual, and are either absent or exist in less quantities in another. 
The fact that acquired immunity is secured by passing through the 
infectious disease in question, points toward this explanation. On 
the other hand it is well known that one attack of one infectious dis- 
ease (malaria, articular rheumatism, croupous pneumonia, erysipelas) 
may predispose to others. In such cases the exciting causes of in- 
flammation must remain within the individual. 



362 THE EYE IN RELATION TO DISEASE. 

Vegetable parasites are by far the more frequent, particularly 
bacteria, while animal parasites are much rarer (as in trichinosis, 
probably malaria, and certain cases of dysentery). 

From these statements it is evident that there will be a certain 
degree of uniformity in the complications and sequelae of all infec- 
tious diseases. Whatever happens in one may be found occasionally 
in all the others. This was shown very distinctly in the last influ- 
enza epidemic which exhibited all the complications and sequelae to 
be found in infectious diseases (la grippe or grip). 

The eye may be the point of entrance of the infection, but this is 
comparatively rare (syphilis, tuberculosis, diphtheria, splenic fever, 
lyssa). Gonorrhoeal conjunctivitis and blennorrhoea neonatorum 
have also given rise to nephritis and swelling of the joints. [Deutsch- 
mann reports finding the diplococci Neisseri in the serous effusion 
taken from the inflamed knee-joint of an infant having purulent con- 
junctivitis. — Ed.] 

The eye is affected somewhat more frequently during the incu- 
bation or prodromal period, and this is not infrequently a guide when 
the symptoms are still entirely indistinct. Conjunctivitis and 
photophobia are characteristic of measles, and oedema of the lids of 
trichinosis, as pains in the throat are characteristic of scarlatina, and 
pain in the back characteristic of variola. 

Diseases of the eye are still more frequently a part of the infec- 
tious disease itself, such as conjunctivitis in measles and. typhoid 
fever, pustules on the lids, conjunctiva, cornea and lachrymal sac in 
variola, spasms and paralyses of the ocular muscles and optic neuritis 
in cerebro-spinal meningitis, diphtheria of the conjunctiva in diphthe- 
ria of the nose and throat, retinal hemorrhages in septicaemia, puru- 
lent inflammation of the choroid and retina in pyaemic processes, 
etc. 

Chronic infectious diseases (syphilis, leprosy, tuberculosis) may 
take effect in the eye and the central parts of the visual apparatus, 
and always as the result of an embolic process. 

The hemorrhages into the lids, conjunctiva and orbit during 
whooping-cough are purely mechanical. Similar conditions may 
be produced by any violent coughing spells, severe vomiting, etc. 



POISONS AND INFECTIOUS DISEASES. 363 

Hsematogenous icterus, which is a symptom, is not infrequently 
the first noticed in the conjunctiva and the last to disappear. 

In infectious diseases, which often give rise to outbreaks of herpes, 
the eruption may appear upon the cornea. It is well known that this 
is frequent in pneumonia, rare in typhoid fever, and is practically 
never seen in meningitis, so that it may be important in differential 
diagnosis. 

The most serious importance attaches to the complications and 
sequelae which affect the eye either directly or secondarily. 

If an acute infectious disease begins with severe symptoms of 
toxaemia, hemorrhages may occur very quickly into the different 
organs, although the microscope does not reveal any change in the 
vessels. An acute scorbutic condition develops and is followed rap- 
idly by a fatal termination. Under such circumstances more or less 
extensive retinal hemorrhages are found, as is well known with re- 
gard to septicaemia, extensive burns, etc. They are much more fre- 
quent than the scanty reports in literature would lead us to believe ; 
they have been found in the dead-house raore often than with the 
ophthalmoscope. They may be present in all " hemorrhagic" infec- 
tious diseases, particularly in hemorrhagic small-pox, in which, how- 
ever, an ophthalmoscopic examination has hardly ever been made. 

When the infection does not begin so acutely, we often find ex- 
tensive acute fatt}^ degenerations, either in the intima of the vessels 
or in the parenchyma of one or more organs. The latter are degen- 
erated diffusely or in patches, especially the liver, kidneys and ner- 
vous system (including the retina) . This is almost always associated 
with inflammatory changes in the vessels, particularly the capillaries 
and small arteries (vasculitis, endovasculitis, perivasculitis). Hem- 
orrhages may occur at the same time or secondarih^ In fatty necro- 
biosis of the parenchyma the direct action of the virus is evidently 
the essential feature. This causes coagulation necrosis and subse- 
quent fatty degeneration, terminating either in restitution by the 
cellular elements which still remain, or in chronic inflammation. 
This is especiall}" frequent in the kidneys which are the chief channels 
of elimination of the poisonous products of disassimilation and, in 
part, of the agents of the inflammation. Hence the frequency of al- 



364 THE EYE IN RELATION TO DISEASE. 

buminuria, sometimes of the most acute hemorrhagic nephritis, at 
the height of the disease. 

When the course is still less acute the action of the virus is chiefly 
expended, apart from the vessels, upon the interstitial connective tis- 
sue, while the parenchyma proper remains healthy or is involved 
only in the stage of retraction of the interstitial process. 

In very chronic infections, the vessels alone are at first attacked. 
They are degenerated very extensively, perhaps only in certain local- 
ities, and often in a manner which is characteristic of the disease. 
They exhibit vasculitis, perivasculitis and endovasculitis, which 
give rise, on the one hand, to narrowing of the lumen and even com- 
plete obliteration, on the other hand to dilatations and aneurisms 
with their sequelae, such as circulatory disturbances, stasis and 
<Bdema, hemorrhages and thromboses. In the retina these changes 
may be ophthalmoscopically visible. 

Although the influence of vascular lesions upon the tissues ap- 
pears to be relatively slight, on account of their very chronic course 
and the possibility of collateral nutrition, they become harmful 
through long duration and may give rise to injury, especially to the 
vulnerable nervous sj^stem, years after the original infection has been 
cured. Such lesions are of a simple atrophic, not of an inflammatory 
character. Focal and systemic diseases of a sclerotic and purely 
atrophic character in the brain, cord and peripheral nerves are due 
not infrequently to infectious diseases, even after the lapse of 
years. 

We may distinguish four principal classes, although they shade 
into one another. 

'1. Acute hemorrhage without noticeable vascular changes (hem- 
orrhages in septicaemia). 

2. Acute hemorrhagic inflammations with acute fatty degeneration 
of the vessels and parenchymatous tissues. 

3. Inflammatory lesions of the vessel, with diffuse inflammatory, 
mainly interstitial, changes; this includes multiple neuritis, the 
cyclitis of relapsing fever, etc. 

4. Chronic inflammatory or necrobiotic lesions of vessels (fatty 
degeneration) without marked interstitial or parenchymatous changes, 



POISONS AND INFECTIOUS DISEASES. 365 

and which rise to simple atrophy after the lapse of years (tabes and 
tabetic atrophy of the optic nerve after syphilis). 

All four forms occur in acute and chronic infections, and may 
even be observed in the same infectious disease, according to the 
acuteness of its development (malaria, syphilis). 

In the affections hitherto considered we have referred solely to the 
poisonous action of the infection. There is also a second factor, which 
constitutes the difference between poisoning and infection, viz., in- 
fectious embolism and thrombosis. As a matter of course, embolism 
and thrombosis may result from the vessel disease alone and then act 
mechanically as an obstruction to the circulation. But if they con- 
tain specific inflammation-producers or the latter colonize in a certain 
part of the tissues, they may give rise to a specific local disease. 
This will var}^ according to the nature of the micro-organism and its 
more or less violent action upon adjacent tissues (necrosis, necrobio- 
sis, inflammation, suppuration, hyperaemia). In many cases the 
specific focus is characteristic and possesses the highest diagnostic 
value. In this sense a pysemic abscess, a diphtheritic inflammatory 
focus, a variola pustule, or an eruption of measles is to be regarded 
as a specific focus, like a typhoid lymphatic gland, a gumma, a nod- 
ule of tubercle or leprosy (so-called specific neoplasms) . 

Such specific foci do not develop in all infectious diseases, partic- 
ularly in those which are very acute and in which the poisonous ac- 
tion predominates (anthrax) . But even those in which focal diseases 
occur constantly may occasionally prove fatal before the outbreak of 
the eruption, if the primary infection is very violent (scarlatina, va- 
riola). 

A less acute infection leads to focal affections which either disap- 
pear without leaving a trace (measles, scarlatina) or they suppurate 
and, if a fatal termination does not ensue, leave cicatrices (pustules, 
abscesses). It is only in comparatively chronic processes that a spe- 
cific neoplasm may be expected. All these cases depend upon quanti- 
tative differences in the action of qualitatively different inflammation- 
producers upon the tissues. 

Not all the focal affections which arise in infectious diseases are 
the direct effects of the specific germs. Many are the results of sec- 



B66 THE EYE IN RELATION TO DISEASE. 

ondary or mixed infection. This is especially true of abscesses. 
These may contain merely the specific germ of the infectious disease, 
provided it possesses pyogenic properties. More often they contain 
pyogenic staphylococci, streptococci, diplococci and bacilli. 

The symptoms of an infectious disease also depend very materially 
upon the nutrient medium or the soil itself, as represented by the in- 
dividual. The infection may not take at all, or its action may be in- 
tensified into acute gangrene, especially during the late stages of the 
disease when the power of resistance of the body has considerably 
diminished. It is often found that specific foci and neoplasms mul- 
tiply with increasing severity the longer the disease has lasted. 

An infectious disease may act favorably or unfavorably upon ex- 
isting e^^e diseases. It has a favorable action when absorption is 
facilitated by the increased process of disassimilation (clearing up of 
pannus, vitreous opacities, etc.), and an unfavorable action when 
chronic inflammations are excited to acute exacerbations (relapses of 
iritis, cyclitis and choroiditis). Acute attacks of glaucoma in eyes 
which suffer from chronic peripheral anterior synechia of the iris and 
cornea may be provoked by an infectious disease, acute myopia may 
develop after measles, necroses may occur in old corneal leucomata 
during many infectious diseases, etc. 

We may summarize the affections of the eye which may occur in 
connection with infectious diseases as follows : 

1. Hemorrhages in all parts of the peripheral and central visual 
apparatus from the most varied causes in all stages of the disease, 
and consecutively every possible disorder of vision, motion and sen- 
sation. 

2. Foci of fatty degeneration and softening in the central organs 
and the eye, visible in the retina with the ophthalmoscope, and often 
associated with hemorrhages. 

3. Inflammatory changes in the vessels in all localities, with the 
above-mentioned consequences. 

4. More or less diffuse inflammations of the tissues of the eye, 
especially of the uvea and retina; iritis, cyclitis, choroiditis, retini- 
tis, diffuse interstitial keratitis, etc. Meningitis with its various 
eye symptoms also develops in the same way. 



POISONS AND INFECTIOUS DISEASES. 367 

5. Changes (chronic and acute hemorrhagic forms) in the optic 
nerve, chiasm, tractus, motor and sensory nerves (multiple neuritis). 

6. Pure atrophy of the nerve tissues (central organs and optic 
nerve) , occurring after the lapse of years and probably the final out- 
come of the vessel lesions. 

7. Focal hypergemias and inflammations (metastases) in various 
degrees from a chronic to an acute hemorrhagic and purulent pro- 
cess, or even terminating in acute gangrene. These are found in the 
integument of the lids (eruptions, sometimes leading to gangrene), 
the sclera (scleritic foci) , uvea (disseminated choroiditis and chorio- 
retinitis, embolic suppurations), retina (benign, but usually septic 
emboli), orbit (metastatic suppurations), lachrymal glands (embolic 
abscesses, dacryo-adenitis), optic nerve and brain, etc. 

8. Specific neoplasms (syphilis, tubercle, leprosy) in almost every 
part of the eye and surrounding structures and in the central nervous 
system. 

The functional results of these lesions are : 

1. Visual disorders of all kinds, of peripheral, intermediate and 
central origin. 

2. Paralyses and spasms of a central, nuclear and peripheral char- 
acter, and even due to direct disease of the muscles. 

3. Neuralgias, anaesthesias and parsesthesias of every possible 
mode of origin. 

4. Other affections, such as adhesion of the lids in conjunctival 
catarrh, disorders of lachrymal secretion and conduction in affections 
of the lachrymal glands and canal, etc. In infectious diseases which 
are attended with high fever and congestion of the meninges and 
cortex, visual hallucinations and illusions are also seen. These 
diseases may terminate in more or less severe forms of insan- 
ity. 

Infectious diseases which have a typhoid stage often lead to des- 
iccation keratitis on account of suspension of winking; protracted 
convalescence causes asthenopic symptoms from weakness of accom- 
modation and convergence; the latter forming part of the general 
muscular weakness. We may find in them the exciting cause of in- 
ternal squint, especially from measles and whooping-cough. 



368 THE EYE IN RELATION TO DISEASE. 

Phlyctenular diseases of the cornea and conjunctiva often develop 
during the period of convalescence. 

In many cases the visual apparatus is affected secondarily by the 
complications of an infectious disease (ursemic amaurosis, retinitis 
and paralyses in renal affections, amblyopia and amaurosis from loss 
of blood, in meningitis, thrombosis of the cerebral sinuses, diseases of 
the vralls of the orbit, etc.). 

During the course of an epidemic, some complication or sequel 
of the infectious disease may be observed in an individual who has 
not suffered from the infectious malady or has only exhibited ill-de- 
fined symptoms. Thus, paresis of accommodation is noticed in epi- 
demics of diphtheria, acute nephritis in epidemics of scarlatina, etc. 
These are undoubtedly the result, in the majority of cases, of an in- 
fection v^^hich has taken an unusual course. 

Among all infectious diseases the greatest resemblance to a toxsB- 
mia is exhibited by 

Septiccemia. 

This is due to the rapid absorption of a large amount of putrid 
virus. It is entirely analogous to the first form of ptomaine poison- 
ing, except that the absorbed ptomaines and toxalbumins are different 
from those there described. Hence, as a rule, mydriasis and paraly- 
sis of accommodation are absent. 

Among eye diseases we need only mention foci of fatty degenera- 
tion and hemorrhages into the retina, which may be found at a very 
early period (second or third day) in acute septicaemia. As a rule 
death then occurs very quickly (although the retinal affection per se 
is benign) , because there is also a tendency to hemorrhage and intense 
degenerations in vital organs. The retinal hemorrhages may also 
possess diagnostic value in so-called spontaneous septicaemia (Leube). 

If the septicaemia does not prove fatal, it usually terminates in 

Pycemia. 

This is the result of the absorption of the agents of inflammation. 
Under their influence the thrombi which have formed at the point 
of reception of the germs undergo softening and parts of the throm- 



POISONS AND INFECTIOUS DISEASES. 369 

bus, laden with the germs, enter the circulation. They then produce 
emboli, thrombi or hemorrhages in other parts, and a purulent focus 
again develops. The point where the germs enter may be situated in 
any part of the body ; external integument (injuries, pressure gan- 
grene, etc.), vesical mucous membrane (cystitis), peritoneum (perito- 
nitis), bones (suppuration from the ears), uterus (puerperal fever), 
etc. The causal disease is sometimes trivial, as, for example, a 
furuncle, small abscess of the lip (Foerster, ?.c., p. 181), a "post-mor- 
tem tubercle," an inflamed phalangeal joint (Leber), even the infected 
wound of a cataract operation (del Toro, Jahr. f. Aug., 1881, p. 288). 

A pysemic focus may develop in any vascular portion of the eye, 
but particularly in the choroid and retina. It appears to be most 
frequent in the retina, probably on account of the small size of the 
vessels and their being " end arteries. " As a rule, septic embolism 
leads to suppuration of the eye and external evacuation of the pus 
after destruction of the cornea. An early fatal termination may be 
predicted with tolerable certainty after the development of pysemic 
suppuration of the eye, but rare exceptions have been observed. 
Hirschberg (Centr. f. Aug., 1883, Sept.), Salo Cohn (/.c, p. 169) 
and Beck {Jahr. f. Aug., 1877, p. 211) mention cases in which pyae- 
mia recovered even after double pysemic panophthalmia. Among 
thirty-five cases of septic general disease Litten (Zeitschr. f. kl. 
Med., II, 3, p. 32) saw three unilateral and five bilateral panophthal- 
mias. 

In rare cases pysemic disease of the eye runs a milder course ; it 
does not terminate in perforation but in simple shrivelling of the 
globe (Landsberg, Berl. kl. Wocli., 1877, No. 38). 

The pus in the eye contains pj^ogenic staphylococci, streptococci, 
diplococci, and even bacilli. 

Pysemic abscesses in the brain, orbital abscesses and thromboses 
of the cerebral sinuses give rise to corresponding eye symptoms. In 
the last days of life, sometimes immediately before death, numerous 
retinal hemorrhages, without suppuration, are observed in cases of 
pysemia. This is a sort of scorbutic terminal stage. 

Weiss (Mon. f. Aug., 1875, p. 393) found double metastatic cho- 
roiditis as the sole pysemic metastasis in a case of compound fracture. 
24 



370 THE EYE IN RELATION TO DISEASE. 

Leber (Jahr. f. Aug., 1880, p. 324) reports unilateral purulent cho- 
roiditis after a " post-mortem tubercle," and bilateral choroiditis start- 
ing from inflammation of a phalangeal joint. During an apyrexial 
puerperal state, Feuer {Centr. f. Aug., 1881, Feb.) saw two abscesses 
develop in the sclera and terminate in suppuration and shrivelling 
of the eye. It is doubtful whether this was a case of pyaemia. 

In a particular case it is not always possible to make a sharp dis- 
tinction between pyaemia and septicaemia, and both may develop to- 
gether or successively. 

Extensive Burns 

resemble pure septicaemia because, on account of the absorption of 
products of decomposition from the burned surface of the skin, an 
acute self -intoxication is produced with a tendency to fatty degen- 
eration and hemorrhage in all the tissues. Retinal hemorrhages are 
often abundant after the third or fourth day. Acute hemorrhagic 
nephritis occurs under the same circumstances, as after poisoning 
with chlorate of potash (Fraenkel, Berl. hi. Woch., 1889, N"o. 2). 

Death may happen from shock at the end of a few hours, or with 
the signs of an acute toxaemia in a few days, or after a still longer 
period from exhausting suppuration. 

As in many other toxaemias, destruction of numerous blood-glob- 
ules, hyaline thromboses, etc., may be demonstrated anatomically. 

In two cases I have seen extensive retinal hemorrhages after se- 
vere burns. There are few reports in literature (Wagenmann, Arch, 
f. OpJith., 34, 2, p. Ill), although they are undoubtedly very frequent. 
Moor en also mentions them. 

Retinal hemorrhages are an unfavorable prognostic sign, but re- 
covery may take place despite their occurrence. 

Glanders 

is substantially, in its clinical history, a pyaemia which has been 
produced by the pyogenic glanders bacillus. The abscess due to the 
latter may also affect the eye. 

In a case of subacute glanders Scheby-Buch (Berl. kl. Woch., 
1878, p. 74) observed purulent conjunctivitis, and also pustules from 



POISONS AND INFECTIOUS DISEASES. 371 

the size of a pea to that of a hazel-nut, upon a red, hard and pain- 
ful base, situated on the forehead, nose and eyelids. In acute glan- 
ders, Boyd (JaJir. f. Aug., 1883, p. 301) noticed an orbital abscess of 
the left side, after abscesses had developed in other parts ; it was at- 
tended with swelling of the lids and exophthalmus and produced 
blindness, although the cornea remained transparent. 

As a matter of course there may be an occasional localization in 
any of the vascular parts of the eye, and this is also true of 

Ulcerative Endocarditis. 

This disease is merely a variety of pyaemia. Its septic, coccus 
emboli may lead to hemorrhages, thromboses and abscesses. In ad- 
dition to miliary foci in many other organs, Michel {Arch. f. Ophth.^ 
XXIII, 2, p. 213) found numerous ecchymoses in the conjunctiva and 
retina, and congestion of the optic nerve. Numerous capillary em- 
boli and miliary abscesses were found in the latter. Doepner (Diss. 
Berlin, 1877) mentions three cases of acute puerperal endocarditis 
with retinal hemorrhages. These would undoubtedly be found very 
often if search were made. 

Splenic Fever, 

anthrax, malignant pustule, malignant oedema, etc., when it does 
not remain localized — as is generally the case in man — produces its 
effects less by embolism than by the impoverishment of nutrition and 
toxic excretions by the baciUi which proliferate with enormous rapid- 
ity. Finally, there develops a sort of scorbutic terminal stage with 
a tendency to hemorrhages. 

One of the favorite sites of infection is the delicate skin of the lids, 
where it may lead to very extensive destruction. The eyelids and 
the angle of the eye are also said to be favorite sites of the Aleppo 
bubo, which is closely allied to anthrax (Altonnyon, Jahr. f. Aug., 
1886, p. 312). 

Tetanus and Lyssa. 

In tetanus it is certain, and in lyssa it is probable, that a specific 
poison is produed by the morbific germs, so that both diseases resem- 



372 THE EYE IN RELATION TO DISEASE. 

ble an acute alkaloid poisoning. Concerning the occasional findings i n 
the visual organ during tetanus, vide page 243. In lyssa the pupils 
are often much dilated ; during the paroxysms the eyes are wide open 
and glistening, and the conjunctiva is congested. I am unacquainted 
with any other eye symptoms in this disease, although hemorrhages 
probably occur as the result of the interference with respiration and 
the fatal suffocation. 

Penzoldt {Berl. kl. Moch., 1882, No. 3) reports a case in which 
the conjunctiva was probably the point of entry of the infection. In 
addition to a bite in the lip, the dog's snout had produced a slight 
wound in the conjunctiva. There were violent pains in the eye dur- 
ing the prodromal stage. 

Rheumatism. 

Acute articular rheumatism must be regarded as an infectious 
disease, although a typical agent of inflammation has not been dis- 
covered or, when found, was not characteristic. The general infec- 
tion in gonorrhoea {vide p. 312) presents great similarity in its clini- 
cal course. In the localizations of the former the same organisms 
are commonly found as in articular rheumatism; the gonorrhoeal 
diplococcus is much less frequent. 

In addition to the well-known outbreaks in the joints and serous 
membranes, acute articular rheumatism produces a series of inflam- 
matory diseases of the eye, such as iritis, cylitis, scleritis and inflam- 
mation of Tenon's capsule, perhaps also glaucoma and parenchymatous 
keratitis. 

Even in the prodromal stage there may be affections of the eye, 
but they are not characteristic, — for example, temporary blindness 
(Woinow, Jahr. /. Aug., 1871, p. 342). Michel {Mon. f. Aug., X, 
p. 167) reported sudden and complete paralysis of the motor oculi, 
probably hemorrhagic in origin. Such conditions are extremely rare. 

Rheumatic iritis is in a measure characteristic. In many cases 
it cannot be distinguished from an ordinary attack, but it is often 
signalized by great pain (spontaneous, on pressure and on moving 
the eye) and the appearance of a coagulating exudation in the ante- 
rior chamber. Even hemorrhages may occur in the latter situation. 



POISONS AND INFECTIOUS DISEASES. 373 

All these sigDS may also be present in iritis from other causes, but 
they are more frequent in rheumatic than in other forms. Purulent 
iritis is very rare (Thiry, Jahr. f. Aug., 1873, p. 283); a grayish 
yellow, so-called cyclitic hypopyon is more frequent. 

The iritis is either synchronous with the joint affection or alter- 
nates with the latter. Relapses are very common. The attacks of 
iritis occasionally recur for years at the same season (Higgens, 
Laqueur, ib., 1874, p. 326). 

Transitions to cyclitis occur in all forms, from the most severe 
to " cyclitis minima" (Boucheron) , in which the main symptom is 
spasm of accommodation. 

Scleritis, inflammation of Tenon's capsule (exophthalmus, che- 
mosis, pain on pressure and on moving the eye) and certain forms 
of glaucoma, especially very acute and painful ones, are also observed. 
The symptoms are not characteristic, except that anti-rheumatic treat- 
ment (salicylate of soda) often exercises a favorable influence on their 
course. In many of these cases, however, it remains doubtful whether 
they are really due to articular rheumatism. 

In the last twenty years I find mention made of only two cases 
of rheumatic optic neuritis (Macnamara, ib., 1890, p. 353). 

Parenchymatous keratitis appears to be associated more frequently 
with articular rheumatism (Arlt, Foerster), but it does not differ 
from the same disease in congenital syphilis. 

The diagnosis of a rheumatic affection of the eye may not be 
made simply because we know of no other cause, or on account of 
the great pain, or the patient's statement that he has caught cold or 
has been exposed to a draught. It is necessary to prove that the 
same noxious agent which produced the disease of the joints and 
serous membranes was also the cause of the disease of the eye, and 
this is rarely possible. 

The large majority of so-called rheumatic muscular paralyses do 
not belong to this category. 

Rheumatic endocarditis is one of the most frequent causes of em- 
bolic processes in the eyes and brain, particularly of benign emboli 
which act mechanically and excite very little or no inflammation. 
There is every possible transition, however, into the severe infectious 



374 THE EYE IN RELATION TO DISEASE. 

emboli of ulcerative endocarditis, which may with equal propriety 
be called pyjemic. 

An unprejudiced survey leads to the conviction that acute articu- 
lar rheumatism is a typical infectious disease, but that it may be 
produced clinically by several micro-organisms (the gonococcus oc- 
casionally produces exactly the same effects) . As the microbes found 
in rheumatism are also met with in other diseases, nothing remains 
but the assumption that the condition and quality of the patient de- 
termine the characteristic course — on the one hand, the localization 
mainly in the joints, the serous membranes, endocardium, occasion- 
ally the eye; on the other hand, the form of inflammation (serous, 
plastic, very rarely purulent) and the peculiar character and course 
of the symptoms. 

The micro-organisms are usually not destroyed entirely or excreted 
in the first attack. Hence, very slight causes may excite a relapse in 
the locus minoris resistentice, i.e., in the tissues and organs which 
have already been diseased. Chronic rheumatism then develops 
under the influence of the repeated inflammations and the consequent 
changes in the processes of disassimilation. Although chronic rheu- 
matism has been regarded as the cause of numerous diseases of the 
eye, this assumption is only justified, in a measure, in regard to cer- 
tain forms of uveitis (iritis, glaucoma) and scleritis. 

Measles. 

Pronounced conjunctival catarrh with more or less photophobia is 
usually present toward the end of the period of incubation and in the 
prodromal stage of measles. When the other symptoms are doubt- 
ful, this may be very important in making an early diagnosis. It 
continues during the eruptive stage and may be associated with 
phlyctenulse. Affections of the cornea are rare in this stage. Ac- 
cording to Galezowski [Jalir. f. Aug., 1887, p. 251), measles may ap- 
pear solely as a phlyctenular conjunctivitis, but it would be very 
difficult to prove this statement in an individual case. 

Other complications are rare. They are, in part, the results of a 
complicating meningitis, like Nagel's three cases of double blindness 
after measles, which was associated with other meningeal symptoms. 



POISONS AND INFECTIOUS DISEASES. 375 

In two of these cases the blindness was permanent, the third case 
slowly recovered. In one of the former the ophthalmoscope showed 
optic neuritis. During convalescence from measles, Graefe also ob- 
served bilateral, complete, but temporar}^ blindness with slight in- 
flammation of the optic nerve and adjacent retina (Foerster, Z.c, p. 
161). 

Other cases of optic neuritis after measles, due in the main to 
complicating meningitis, have been reported. Wadsworth {Arch, 
f. Aug., X, 1, p. 100) reports three cases, one terminating in atrophy 
of the nerve and blindness, one in death, one complicated by abdu- 
cens paralysis. Carreras Arago {Centr, f. Aug., 1882, Oct.) ob- 
served one fatal case, and Galezowski {Jahr. f. Aug., 1881, p. 401) 
also reports a case. 

Measles is followed very often by suppuration from the ear. This 
may give rise to meningitis and then involve the eye. For example, 
Keller {Mon f. Ohr., 1888, No. 6) reports a case of acute catarrh of 
the middle ear followed by double choked disc and left abducens 
paresis. 

V. d. Stok {Arch. /. Aug., 1888, p. 391) describes a case of right 
hemiplegia and hemianopsia, terminating in recovery, after the dis- 
appearance of the measles eruption in a man aged twenty years. 

Among the sequelae during convalescence and later, special atten- 
tion should be drawn to phlyctenular diseases of the conjunctiva and 
cornea. They are often very severe and obstinate a,nd occasionally 
lead to destruction of the cornea (Dujardin, Jahr. f. Aug., 1868, p. 
247, ten cases). Obstinate eczema of the lids and their edges is also 
frequent. 

Keratomalacia after measles has been reported by Bezold {Berl. 
kL Woch., 1874, p. 408), Fischer and Beger {Jahr, /. Aug., 1874, 
p. 310). 

A very rare symptom is spontaneous gangrene of the lids. Noma 
is much more frequent and may extend to the lids. Fieuzal {Jahr. 
f. Aug., 1887, p. 422) describes three cases of gangrene of the upper 
lid terminating in ectropium. In one infant I observed spontaneous 
gangrene of all four lids, approximately in the locality where xan- 
thelasma usually develops. Recovery was attended by a deep scar 



376 THE EYE IN RELATION TO DISEASE. 

but without deformity, inasmuchi as the edges of the lids had re- 
mained intact. 

Lindner (Wien. med. Woch., 1891, p. 683) observed an acute in- 
flammation of both lachrymal glands with considerable swelling of 
the cervical, sublingual and submaxillary glands, after measles, in a 
boy of eight years. Adler (" 3. Ber. d. Krankenh. in Wieden") also 
observed dacryo-adenitis after measles in a boy of seven years. 

Horner {Mon. /. Aug., I, p. 11) reports retinitis albuminurica 
after measles. This is not surprising in view of the fact that renal 
affections often follow measles. 

Fialkowsky (Jahr. f. Aug., 1888, p. 538) claims to have seen re- 
covery of trachoma, ectropium and pannus as an effect of the increased 
disassimulation during measles, while Hirschberg observed, under 
similar circumstances, spontaneous necrosis and ulceration of a leu- 
coma adhserens, followed by granuloma of the iris. 

EoetJieln {Bastard Measles). 

Among my notes I find mention made by St. Martin of a case of 
facial paralysis and gangrene of the upper lid after roetheln. 

Scarlatina. 

This gives rise to conjunctival catarrh in quite a proportion of 
cases, but by no means so constantly as measles. 

The most important affections of the eye are due to complications. 
Acute nephritis, which often develops very suddenly, may produce 
ursemic blindness. This is generally associated with eclamptic at- 
tacks, often with oedema of the lids; the reaction of the pupils to 
light may be retained or absent. Less acute diseases of the kidney 
may cause retinitis albuminurica, and the latter is occasionally com- 
bined with the ursemic disorder of vision. 

On the whole, the prognosis of these acute infectious renal dis- 
eases and their effects upon the eye is better than when the former 
develop independently of infection, but partial atrophy of the optic 
nerve may also follow scarlatina. JSTot infrequently chronic nephritis 
is the result, and this may prove fatal long afterward, for example, 



POISONS AND INFECTIOUS DISEASES. 377 

after the lapse of twenty years in Aufrecht's case {Jahr, f. Aug., 
1888, p. 571). 

Scarlatinous nephritis may appear after very mild attacks of 
scarlatina. Hutchinson {Jahr. f. Aug., 1871, p. 293) even speaks 
of scarlatinous renal retinitis without an eruption. 

Complicating meningitis may produce optic neuritis, spasms and 
paralyses of the eye muscles ; when it runs a chronic course it may 
lead to deafness and idiocy. 

Despite the frequent coincidence of pharyngeal diphtheria, post- 
diphtheritic paralysis of accommodation is quite rare. It should not 
be mistaken for the simple weakness of accommodation during con- 
valescence. Other muscular paralyses after scarlatina are also rare. 

Severe phlyctenular affections of the conjunctiva and cornea, and 
aural suppuration with its results (facial paralysis, meningitis, etc.) 
are more frequent after scarlatina than after measles. Alt (Arch. f. 
Aug. u. Oht\, 1878, p. 54) observed post-scarlatinous kerato-malacia, 
without disease of the lids or trigeminus paralysis. 

Diseases of the lachrymal sac are also quite common. Kendall 
(Brit. Med. Journ., 1883, I, p. 1,225) reports a case of this kind 
associated with suppuration of the right eye. 

Atrophy of the optic nerve from orbital inflammation is reported 
by Nettleship {Jahr. f. Aug., 1880, p. 282, Case 3), who also describes 
(^6., 1886, p. 248) an erysipelatous orbital suppuration after scarlatina, 
which gave rise to optic atrophy. 

Lindner {Wien. nied. Woch., 1891, No. 16) reports two cases of 
purulent inflammation of the lachrymal gland with scarlatina, while 
dacryo-adenitis after measles does not lead to suppuration. He claims 
that scarlatina is a more pyogenic affection than measles. 

The embolism of the central artery of the retina, observed by 
Hodges {Jahr. f. Aug., 1885, p. 260) in a girl of eighteen years dur- 
ing convalescence, was probably a mere coincidence, although a cau- 
sal connection cannot be absolutely denied. 

Schiess reports a case of partial albinism of the upper lid after 
scarlatina. A white streak was situated on the forehead and right 
upper lid ; the brow was perfectly white in one place, the eyelashes 
partly white, partly black. This part was also free from freckles 



378 THE EYE IN RELATION TO DISEASE. 

which covered the rest of the face. Motion and sensation were nor- 
mal. Although there can be no doubt of a causal connection between 
infectious diseases and such trophic disturbances, no definite locali- 
zation (superior cervical ganglion?) has yet been ascertained. 

Small'pox. 

Compare Manz (Jahr. f. Aug., 1871, p. 178) and Adler (Viertel- 
jahr. /. Dermat. u. Syph., 1874). The eruption of small-pox 
may attack the eye. According to Adler {ib.) it appears upon the 
integument of the lids in twenty per cent of the cases. If the pus- 
tules are very numerous, oedema develops ; if they are hemorrhagic, 
blood will be found in the lids. Erysipelas, phlegmons, abscesses 
and furuncles of the lids are not uncommon results. Pustules 
upon the free border lead to partial trichiasis, ankyloblepharon, etc. 
Ciliary seborrhoea and blepharitis ensue not infrequently. We then 
find hordeolum, chalazion, ectropium, thickening of the lids, trichi- 
asis and distichiasis ; also bending and shrinking of the lids if the 
process has extended more deeply. Caries and periostitis of the rim 
of the orbit have also been observed (Landesberg, Jahr. f. Aug., 
1874, p. 505; Magnus, ib., 1887, p. 133). 

The conjunctiva often exhibits congestion and catarrh, especially 
when the lids or their edges are affected. There may even be blen- 
norrhoea, with chemosis and conjunctival hemorrhages. If pustules 
develop upon the conjunctiva, an ulcer alone is visible because the top 
of the pustule is soon exfoliated. They look exactly like large phlyc- 
tenulse, and even large ones may heal without any bad after-effects. 
But if they are situated, as frequently happens, at the edge of the 
cornea, progressive corneal suppuration with hypopyon is apt to de- 
velop. This may heal at any stage — often with a very characteristic 
sickle-shaped opacity of the cornea. It often leads to loss of one eye 
or both, especially in variola which has not been modified by vacci- 
nation. According to Geissler the loss of both eyes after variola is 
rare only because such individuals usually die. Extensive conjuncti- 
val hemorrhages may occur in hemorrhagic small-pox. 

Some deny (Adler, Foerster), others affirm (Horner) the develop- 



POISONS AND INFECTIOUS DISEASES. 379 

ment of primary pustules on the cornea, but at all events they are 
rare. 

The fact that purulent keratitis often does not begin until one or 
two weeks after the outbreak of the eruption, or even during the 
period of convalescence, shows that the progressive suppuration is 
due to secondary infection of the pustules.' Severe corneal suppu- 
rations of this kind are found in bad cases of small-pox and in ma- 
rasmic individuals. Simple marasmic keratitis (kerato-malacia) 
also occurs under such circumstances. 

Acute and chronic inflammations of the lachrymal passages are 
frequent in small-pox, and often from the formation of pustules upon 
their mucous membrane. 

Pustules upon the eye are rarer in varioloid and run a milder 
course than in true variola, although even mild cases sometimes cause 
severe affections of the eye. 

Among the complications of small-pox meningitis is very rare, 
while renal disease is frequent. Ursemic disturbance of vision or ret- 
initis albuminurica may be observed at an earlier or later period. 

Retinal hemorrhages undoubtedly occur in hemorrhagic small-pox, 
although I find no references in literature. Hemorrhages into the 
optic nerve will also occur occasionally, and there is no doubt that 
such hemorrhages near the entrance of the nerve must have been the 
cause of some of the affections described as neuritis with and with- 
out stasis, and with or without termination in optic nerve atrophy. 
Adler (I.e.) describes two cases of diffuse neuro-retinitis as the pus- 
tules passed into the stage of desiccation; both recovered. 

Sequelae of small-pox are rare, and do not develop until after the 
third week. We may mention diffuse iritis (associated, in hemor- 
rhagic small-pox, with hemorrhages into the anterior chamber), 
cyclitis, choroiditis ; in many cases the latter affections are only re- 
vealed by opacities in the anterior or posterior part of the vitreous, 
as in relapsing fever. This sometimes terminates, at a later period, 
in cataract (Romiee, Hutchinson). According to Adler (I.e.) many 

^ Hence it follows that the destructive suppuration of the pustules can be 
prevented by strict antisepsis or asepsis. Even if this cannot be done over the 
entire body, excellent results would follow its employment in the face alone. 



380 THE EYE IN RELATION TO DISEASE. 

cases exhibit merely ciliary irritation, i.e., ciliary injection, photo- 
phobia and epiphora, without decided inflammatory symptoms. 

Localized diseases of the choroid may also occur after small-pox. 
I have seen several chorio-retinitic foci in the fourth week. Re- 
tinitis is undoubtedly very rare, but Manz mentions a case. 

Outbreaks of glaucoma, due to small-pox, have been reported by 
several writers. 

Parenchymatous keratitis after small-pox has been reported by 
Adler (Z.c.) and Bock {Centr. f. Aug., 1890, p. 361). More or less 
severe phlyctenular diseases are much more frequent. 

Paralyses of the eye muscles and central disorders of sight are 
very rare. Wohlrab {Jahr. f. Aug., 1872, p. 512) observed aphasia 
in varioloid and, during the fourth week, neuro-paralytic keratitis. 
Both were probably due to meningitic processes. 

Geissler {Arch. f. Heilk., 1872, p. 549) noticed complete and per- 
manent clearing of an old corneal opacity during variola, while the 
previously healthy cornea of the other eye was destroyed. 

Vaccination. 

The laity generally attribute to vaccination everything that hap- 
pens to a child in the first year of life. It cannot be denied that 
phlyctenular diseases of the conjunctiva and cornea, eczema of the 
face, etc., may follow vaccination, as they do many other infectious 
diseases. In feeble children such affections of the eye are occasion- 
ally quite severe and protracted. If these affections occur long after 
vaccination, as usually happens, there can be no ground for admitting 
the causal influence of the vaccination. 

The vaccine virus is sometimes inoculated accidentally upon the 
lids or in the conjunctival sac. A typical vaccine pustule may be 
produced in this way (Hirschberg, Arch. f. Aug., VIII, p. 166; 
Senut, Jahr. f. Aug., 1886, p. 440; Berry, Brit. Med. Journ., 1890, 
p. 1,483). Hirschberg {Jahr. f. Aug., 1885, p. 464) also mentions 
a vaccine blepharitis from the introduction of lymph into the conjunc- 
tival sac. In the case of a physician who accidentally struck himself 
in the eye while vaccinating, Critchett {ih., 1876, p. 268) observed 
violent keratitis with sero-purulent infiltration of the cornea, despite 



POISONS AND INFECTIOUS DISEASES. 381 

immediate irrigation of the eye. The keratitis terminated in a leu- 
coma, i.e., a vaccine pustule of the cornea. Vaccine pustules of the 
eye are most apt to develop on the free borders of the lids and in the 
canthi. [A picture of the appearance of the lids when vaccine in- 
fection attacks them is given in the editor's text-book of diseases of 
the eye, Plate VII. See description, p. 816. — Ed.] 

If syphilis is transmitted in vaccination, any of the syphilitic 
affections of the eye may follow, among which iritis is usually the 
earliest. 

After vaccination at the age of five years, Tilly {Journ. of the 
Amer. Med. Assn., Feb. 4th, 1888) observed pemphigus of both con- 
junctivae (in addition to other parts). Within a year this caused 
loss of sight by obliteration of the conjunctival sac. The coincidence 
of the two affections seems to me to have been accidental. 

Varicella. 

Apart from eruptions upon the lids, varicella rarely produces eye 
symptoms. According to Comby (Jahr. f. Aug., 1884, p. 323), the 
eruption on the lids sometimes precedes that on other parts of the 
body. Steffan {ib., 1873, p. 284) noticed purulent iritis with hypo- 
pyon during convalescence from varicella in a child of three years ; 
the case terminated fatally. As this case is unique it is impossible 
to determine whether the coincidence was accidental or not (possibly 
due to secondary or mixed infection). 

As nephritis is sometimes found after varicella (Oppenheim, He- 
noch, Janssen), this might occasionally give rise to eye symptoms. 
As the varicella may run a very mild course and is often hardly 
noticed, it would be difficult to recognize sequelae as such, especially 
if they do not develop until after the lapse of several weeks. 

Typhoid Fever. 

In typhoid fever the eje may be attacked during the disease or 
at a later period. Conjunctivitis in varying degrees of severity is 
not uncommon. During convalescence, paresis of accommodation 
with dilatation of the pupil is very frequent, not as a true paralysis 
but as a part of the general weakness. True paralyses of the eye 



382 THE EYE IN RELATION TO DISEASE. 

muscles may also begin long after the disease has run its course. 
Considerable dilatation of the pupil is often noticed, despite normal 
vision and accommodation (Segal, Afxh. f. Aug.^ 1888, p. 386). 
During convalescence, and still more at a later period, there is a great 
tendency to phlyctenular affections of the conjunctiva and cornea, 
even passing into kerato-malacia. This should not be mistaken for 
marasmic xerosis cornese, which develops in the somnolent stages 
of typhoid from desiccation of the conjunctiva and cornea and sub- 
sequent external infection. Next to cholera this is observed most 
frequently in typhoid fever. 

Temporary and permanent impairment of sight may also be pro- 
duced by neuritis or retrobulbar neuritis, with or without subsequent 
atrophy of the optic nerve. A complicating meningitis often forms 
the connecting link between the infectious disease and the affection 
of the optic nerve. Yon Petershausen {Jalir. f. Aug., 1873, p. 362) 
reports double neuro-retinitis with macular hemorrhages during 
typhoid fever ; Munier (^6., 1875, p. 345) describes neuro-retinitis and 
deafness, evidently as the result of meningitis. The first eye was 
attacked three months after the typhoid fever, the second eye four 
months later. 

Meningitic processes, or "irritation" with more or less involve- 
ment of the cortex, are evidently quite frequent and probably the 
main cause of the delirium and hallucinations. At the base of the 
brain they give rise to optic neuritis, irritation and paralyses of the 
nerves; at the convexity they may cause cortical disorders of vision, 
hemianopsia (very rare) and double amaurosis without findings, 
especially in children. The cause of an hemianopsia may also be 
located in the tractus. 

Leber and Deutschmann {Arch. f. Ophth., XXVII, 1, p. 272) 
reported a case of double blindness with secondary atrophy of the 
optic nerve and pigmentation of the entrance of the nerve. Seggel 
{Jahr. f. Aug., 1884, p. 323) reported a case of impaired vision dur- 
ing the second week ; rapid improvement in the right eye — with the 
left only movement of the hand could be seen, and later there was 
atrophy of the optic nerve. Both these cases must be regarded as 
retrobulbar neuritis, probably from hemorrhage into the optic nerve. 



POISONS AND INFECTIOUS DISEASES. 383 

Unilateral and bilateral iritis, cyclitis, choroiditis, chorio-retinitis, 
•etc. , are also met with, but not as often as in relapsing fever. They 
occur in serous and plastic forms, and are often complicated with 
opacities of the vitreous. Cataract may develop more or less rapidly 
as the result of these uveal diseases, for example, Arens {Jalir. f. 
Aug., 1885, p. 428, ripe cataract in two young sisters a year after 
typhoid fever), Trelat {Gaz. des Hop., 1879, p. -117), Romiee, Fon- 
tan {Eev. gen. cVOphth., April, 1887), etc. In such cases the exam- 
ination of the urine should not be neglected, because diabetes may 
occur as a sequel of typhoid fever. 

In muscular paralyses occurring some time after typhoid fever 
(Runeberg, Jahr. f. Aug., 1875, p. 501; left trochlear paralysis one 
and one-half years afterward), albuminuria should always be looked 
for as the intermediate cause. Chronic nephritis is a quite frequent 
sequel of typhoid fever, and appears to me to possess in these cases 
a certain tendency to the production of paralyses of the eye muscles. 
These recover quickly and also relapse quickly, and are nuclear in 
character, I cannot regard it as a mere coincidence that almost all 
the albuminuric paralyses which I have seen of late years could be 
attributed to a previous typhoid fever. During the fever the paraly- 
ses are very rare. ISTothnagel reports double ptosis and right abdu- 
cens paralysis, with aphonia, at the beginning of the third week 
(Foerster, I.e., p. 167). 

Noma may also extend to the eyelids and, if recovery occurs, may 
give rise to ectropium. It is well known, however, that the major- 
ity of such cases terminate fatally. 

Profuse hemorrhage is a not infrequent cause of amblyopia and 
amaurosis {vide p. 290). It is usually intestinal, but an epistaxis 
(Ebert, Berl. kl. WocJi., 1868, p. 21) or menorrhagia (Williams) 
may also act as the cause. 

Psychoses, focal and systemic diseases of the brain and cord are 
occasional sequelse, which sometimes do not develop until after the 
lapse of years. They may give rise to a corresponding affection of 
the organ of sight. Proelss (Diss. Berlin, 1886) observed after 
typhoid fever a paralysis of the cervical sympathetic which termi- 
nated in facial hemiatrophy. 



384 THE EYE IN RELATION TO DISEASE. 

Typhus Fever. 

Very little has been published concerning affections of the eye 
during and after typhus fever. They are probabty similar to those 
following typhoid and relapsing fever. 

According to Salomon {Jahr. /. Aug., 1880, p. 239), conjunctival 
catarrh is a constant symptom and exhibits very striking injection 
of the bulbar conjunctiva. This is not true, however, of all epidemics. 

The uveal inflammations which are so frequent after relapsing 
fever are also found after typhus, though not so frequently. Hers- 
ing {Arch. f. Ophth., XVIII, 2, p. 69) reports an annular, equatorial 
chorio-retinitis, with hemeralopia and annular scotoma, after typhus 
fever. 

In a patient aged twenty-eight years, Lindner {Wien. Med. 
Woch., 1891, p. 283) observed an acute inflammation of the lachrymal 
glands without suppuration ; death occurred upon the tenth day. 

Relapsing Fever. 

Vide Jahr. f. Aug., 1870, p. 319; Logetschinkoff (Arch. f. 
Ophth., XVI, 1, p. 353); Foerster (I.e., p. 169); Brieger (Charite- 
Annal., VI, p. 136); Haenisch (Deutsch. Arch. f. kl. Med., V, p. 
53); Peltzer {Berl. kl. Woch., 1872, No. 37); Estlander {Arch. f. 
Ophth., XV, 2, p. 108), etc. 

Conjunctival catarrh is a frequent symptom in relapsing fever. 
At the height of the attacks there may be temporary unilateral or bi- 
lateral disorders of vision, even blindness (Brieger, I.e.). As is 
shown by the reaction of the pupils to light, these may be due to 
peripheral as well as central action, and perhaps result, in part, from 
the direct action of the virus. 

The symptoms during convalescence resemble those after typhoid 
fever, viz. , weakness of accommodation, temporary enlargement or 
inequality of the pupils, tendency to phlyctenular diseases, etc. 

The most characteristic sequel is commonly called cyclitis, although 
all parts of the uveal tract may be affected separately or in combina- 
tion. Simple plastic iritis is comparatively rare; while the serous 
type, with deposits upon the posterior wall of the cornea, and perhaps 



POISONS AND INFECTIOUS DISEASES. 385 

hypopyon, is more common. Cyclitis and choroiditis are manifested 
chiefly by vitreous opacities. In mild cases a ring of opacities is 
detached from the ciliary body and is slowly absorbed in the anterior 
parts of the vitreous body. In severe cases the entire vitreous is 
more or less filled with opacities and there is more or less impairment 
of sight. The deficiency may be much more pronounced than the 
density of the opacities would lead us to believe. If the fundus is 
visible, the ophthalmoscope shows merely a reddened disc. The cho- 
roiditis is not visible with the ophthalmoscope, because it is diffused 
and the pigment epithelium is very slightly changed; it is shown 
only by the vitreous opacities, but a part of these are undoubtedly 
derived from the retina. The implication of the latter is undeniably 
the cause of the disproportionate impairment of vision. After the 
disease has run its course, disseminated changes are found not infre- 
quently" in the anterior part of the choroid. 

The disease of the eye must then be regarded as a diffuse inflam- 
mation of the uvea, which usually reaches its greatest intensity in 
the region of the ciliary body. It appears in all possible degrees of 
acuteness, from hardly visible ciliary injection to the most violent 
inflammatory phenomena ; and the pain will be in proportion to their 
intensity. There are also transitions to the plastic-purulent forms, 
such as are peculiar to meningitis. In severe cases the tension of 
the eye is considerably diminished ; shrinking of the vitreous, detach- 
ment of the retina and, finally, phthisis bulbi may ensue. Secondary 
cataract is rare and appears usually as posterior cortical cataract. 

This uveitis is essentially a sequela ; it rarely begins between or 
during the attacks, usually not until the third week, and occasionally 
much later. 

The prognosis is generally favorable. Complete recovery occurs 
after the lapse of weeks and months by the gradual absorption of the 
vitreous opacities. On the other hand, complete loss of one eye or 
even of both eyes may result from pupillary occlusion, vitreous opac- 
ties and detachment of the retina. More or less dense vitreous 
opacities may also persist for a long time. 

The frequency and severity of ocular complications vary in differ- 
ent epidemics. In some they are found in nearly ninety per cent of 
25 



386 THE EYE IN RELATION TO DISEASE. 

the cases, in others in very few. In about twenty per cent the 
trouble attacks both eyes. Mild epidemics may be attended by nu- 
merous and severe diseases of the eye, severe epidemics by rare and 
mild affections. Men are attacked more frequently than women. 

It is evident that the virus of the disease slowly produces certain 
tissue changes, in great part, probably, in the vessels. These are 
followed after a while by a more or less acute interstitial inflamma- 
tion (vide p. 363), on account of some unknown cause (embolism or 
thrombosis?). In view of the great vascularity of the uvea, it is not 
astonishing that this should be affected so often. Moreover, diseases 
in this region are most apt to produce subjective and objective symp- 
toms. A similar process in another locality would produce very 
vague symptoms or none at all. Even in the pia mater, which is 
genetically co-ordinate and equally vascular, an analogous condition 
would not produce notable symptoms until it had acquired consider- 
able extent. However, symptoms of a more diffused or circumscribed 
meningitis are frequent in all forms of typhoid disease. Like the 
uveitis of relapsing fever, the meningitis of non -pyogenic infectious 
diseases also recovers completely, as a general thing, but sometimes 
leads to very annoying complications and sequelae. 

The uveitis which has just been described occurs most frequently 
in relapsing fever, but is also found in other typhoid affections, small- 
pox, influenza, etc. 

Every possible transition is found between it and the typical plas- 
tic, purulent irido-choroiditis of simple and cerebro-spinal meningitis, 
and also purulent inflammation of the choroid and retina in pysemic 
processes. 

Very little has been published concerning any other complications 
and sequelae of relapsing fever. 

Cholera. 

Vide Foerster (Z.c, p. 177), Graefe {Arch. f. Ophth., XII, 2, p. 
198). 

The characteristic changes in the eye are those which depend 
upon the loss of the serum of the blood and tissues, and the conse- 
quent interference with circulation. Similar changes in a milder 



POISONS AND INFECTIOUS DISEASES. 387 

form are also seen in cholera morbus and cholera infantum. As a 
matter of course the face and eyelids take part in the often striking 
and general cyanosis. 

On account of the loss of fluid in the orbital tissues, the eyeball 
sinks deep into its socket ; the loss of fluid in the lids causes them to 
shrink so that they are closed imperfectly. It is true that the volun- 
tary action of the orbicularis palpebrarum will close the lids, but dur- 
ing sleep the palpebral fissure is more or less open and the imperfectly 
covered eyes are rotated upward. The lowermost part of the cornea 
and the bulbar conjunctiva below it are thus exposed to external in- 
jurious influences. Hypersemia and inflammation of the exposed 
conjunctiva develop, but usuallj' not until the stage of reaction. In 
severe cases these parts become desiccated (xerosis). This is facili- 
tated by the complete apathy of the patient in the typhoid stage. 

Spontaneous hemorrhages into the conjunctiva sometimes occur 
and have a very grave prognostic import. Xerotic keratitis is also 
very ominous, although it may possibly heal at any stage after exfo- 
liation of the dried slough. In favorable cases, a more or less ex- 
tensive leucoma is left upon the lower half of the cornea. 

In very severe cases slaty-gray patches of irregular shape occa- 
sionally appear below or alongside the cornea. As they may also 
develop beneath the closed lid, they cannot always be due to simple 
drying of the conjunctiva and sclera. According to Boehm and 
Graefe they are the result of the loss of fluid in the corresponding 
part of the sclera. It appears much more probable to me that in 
those cases which may not be attributed to simple desiccation, we 
have to deal with choroidal hemorrhages which shine slaty-gray 
through the thinned sclera. Such extravasations have been found in 
a number of autopsies, and the very rapid development of these 
patches also favors this theory. 

It is readily understood that the lachrymal and conjunctival se- 
cretion is diminished. 

At the height of the disease the retinal arteries are seen to be 
narrow, filled with dark blood, and are readily made to pulsate or 
even emptied by pressure. The more marked these appearances are, 
the more unfavorable is the prognosis, because the ophthalmoscopic 



388 THE EYE IN RELATION TO DISEASE. 

findings simply represent the general condition of the blood and the 
blood pressure. The veins are also very dark, their calibre un- 
changed, the column of blood sometimes interrupted, and the circu- 
lation then takes place by fits and starts as happens during restoration 
of the retinal circulation after embolism of the central artery of the 
retina. 

Vomiting might possibly result in the same disorder of vision as 
losses of blood {vide p. 290) , but no reports are furnished in literature. 
Perhaps this explains Roorda Smit's case {Arch. f. Aug. , XYIII, 
3, p. 383), in which a previously healthy man of forty years became 
entirely blind within two weeks after an attack of cholera and later 
exhibited atrophy of the optic nerve (so-called retrobulbar neuritis, 
probably retrobulbar hemorrhage into the optic nerve) . 

The condition of the pupils varies, but they are usually contracted. 
During the attack, Campart and St- Martin {Jahr. f. Aug., 1885, p. 
356) often found pronounced mydriasis and inequality of the pupils; 
sometimes unilateral and bilateral myosis without any change in 
accommodation. Myosis predominated toward, the end of the attack. 
According to Joseph, myosis is also present in the typhoid stage and 
mydriasis is only found in severe collapse (Foerster, I.e., p. 178). 
According to Corte {Deutsch. med. Woch., Jan. 22d, 1891), the con- 
dition of the pupils during the algid stage decides the prognosis. If 
the reaction to light is preserved, the prognosis is favorable whether 
the pupil is narrow or wide, and however violent the other symptoms 
(cyanosis, collapse, pulselessness, etc.) may be. Among sixty-six 
patients with intact reaction of the pupils to light, all recovered ; a 
fatal termination is, however, possible during the stage of reaction. 
If the pupils are immovable we may be certain of a fatal termination 
despite the slight severity of the symptoms and the restoration of 
various functions. 

Little is known concerning sequelse of cholera, so far as they 
affect the eye. The same conditions may occasionally develop as 
after other infectious diseases. Williams {Jahr. f. Aug., 1885, p. 26) 
reports a case of iritis after cholera, and also reports another in which 
the iritis was cured by an attack of cholera. Delens {ib., 1886, p. 475) 
reports a cure of leuksemic orbital tumors by an attack of cholera. 



POISONS AND INFECTIOUS DISEASES. 389 

Dysentery. 

Disorders of sight play a comparatively insignificant part in this 
disease. It often leads to nephritis, and occasionally the effects of 
the latter will be observed in the organ of sight. Muscular paraly- 
ses, similar to those after diphtheria, have been attributed in a few 
cases to dysentery. Marcisiewicz (Wien. med. Presse, 1888, p. 
561) describes an inflammation of both lachrymal glands as a sequel 
of dysentery. 

Diphtheria. 

In this disease eye symptoms play an important part. We will 
not consider diphtheritic affection of the conjunctiva and lids, which 
may occur either independently or in combination with the same 
disease in the nose, pharynx and larynx. Apart from these, the 
most important sequelae are paralyses of various kinds. Special im- 
portance attaches to paresis, more rarely to complete paralysis of 
accommodation. As a rule, it begins a few weeks after the diphthe- 
ria has run its course and usually disappears spontaneously in four 
to eight weeks. It is almost always bilateral, and the pupil is hardly 
ever affected. Hence some suspicion attaches to Jeaffreson's case 
(Foerster, I.e., p. 172) of unilateral paralysis of accommodation after 
diphtheria, because there was mydriasis on the same side. The 
paresis of accommodation is often isolated, but there may also be 
other post-diphtheritic paralyses, especially in the larynx and pharynx. 
The large majority of cases occur in children. 

This characteristic paralysis may occur after diphtheria of all 
localities (conjunctiva, vulva, wounds, etc.), but is most frequent 
after pharyngeal diphtheria. It may follow mild cases and even 
those which have been entirely overlooked. It is not impossible 
that a diphtheritic general infection and subsequent paralysis may 
develop without any visible localization. During epidemics of diph- 
theria, typical paresis of accommodation, occasionally in conjunction 
with other paralyses, may be observed although there has been no 
trace of previous local disease. In other cases, the patient suffers 
from pain in the throat or difficulty in swallowing, but the most care- 
ful examination fails to reveal any diphtheritic membrane. In these 



390 THE EYE IN RELATION TO DISEASE. 

cases, however, typical paresis of accommodation must be regarded 
as evidence of previous diphtheritic infection. 

During this paresis of accommodation, refractive power is some- 
times moderately diminished, especially in latent hypermetropia, or 
slight astigmatism becomes manifest. Adams {Lancet, 1882, No. 
4) observed violent spasm of accommodation following a diphtheritic 
paresis. 

According to Hasner {Wieii. med. Zeit., 1873, p. 120) a frequent 
complication of the paresis is congestion of the retina with impair- 
ment of vision which recovers very slowly. In the many cases which 
I have seen the fundus has always been found normal. 

Paralyses of other eye muscles, with or without paresis of accom- 
modation, are also occasionally seen after diphtheria. Squint is 
mentioned in a number of cases. Callan {Jalir, f. Aug., 1875, p. 
485) reports double paralysis of accommodation with left hemiplegia 
and incomplete ptosis ; Rumpf {ih., 1877, p. 381) describes double 
paralj^sis of accommodation and of the internal recti. Henoch re- 
ported double abducens paralysis {Deutsch. med. Woch., 1889, No. 
44) ; this was possibly a spasm of convergence, like Rosenmeyer^s 
{I.e.) two cases of paresis of both externi. 

Complicated paralyses of the eye muscles also occur. Uhthoff 
{Berl. hi. Woch., 1884, p. 318) reports complete ophthalmoplegia 
externa and slight ptosis, with preserved reaction of the pupils, after 
a paresis of accommodation. Mendel {Centr. f. Aug., 1885, p. 89) 
reports bilateral paralysis of all the recti muscles, not complete on the 
right side; fatal termination. Two weeks after an apparently very 
mild attack of diphtheria, Ewetzky {Jahr. f. Aug., 1887, p. 253) ob- 
served bilateral total ophthalmoplegia externa and ptosis, with 
paralysis of the velum palati ; recovery in three weeks. 

Even in these complicated cases the prognosis is good unless 
death is due to other causes. 

Sensory disorders are also observed in the eye. Laqueur {Mon.f. 
Aug. , XV, p. 228) reports right facial and trigeminus paralysis, ter- 
minating in neuro-paralytic keratitis and loss of the eye. The paraly- 
sis of the trigeminus recovered partially, that of the facial nerve 
completely. 



POISONS AND INFECTIOUS DISEASES. 391 

The majority of these paralyses developed after pharyngeal diph- 
theria. After diphtheria of the eye, Politzer {Jalir. f. Kinderh., 
1870, p. 335) observed purulent cerebro-spinal meningitis and puru- 
lent inflammation of several joints, evidently a pyaemia due to sec- 
ondary or mixed infection. After diphtheria of the conjunctiva, 
with implication of the nose, Dubois {Prog. Med., May 7th, 1887) 
saw paralysis of the velum palati and lower limbs. 

The paralyses are rarely central or nuclear, but usually periphe- 
ral. In most cases v/e have to deal with hemorrhages or neuritis or 
with hemorrhagic neuritis. This affects mainly the nerve roots and 
peripheral nerves, but sometimes the nuclear region, and, in rare 
cases, more central portions (Krause, Neurol. Centr.., 1888, No. 
17). Decided evidences of inflammation have also been found in the 
muscles (Hochhaus, Virch. Arch., 121, 2). It is doubtful, however, 
whether all post- diphtheritic paralyses develop in this way. The 
very frequent paralysis of the velum palati is regarded by many as a 
direct local effect of the virus. Typical paresis of accommodation 
is also explained with difficulty by hemorrhagic or inflammatory 
processes in any locality. It is very evident that during a certain 
stage of diphtheria, or after the attack, a definite ptomaine is produced 
and that this has a paralytic action upon accommodation, while it 
has no influence on the movements of the pupil. Otherwise it is 
impossible to understand why accommodation alone is paralyzed, 
and why the paralysis is not complete but is bilateral in almost every 
case. 

Disturbances of vision after diphtheria may also be due to diplopia, 
which is not usually recognized at once b}^ the patient. But dis- 
orders of sight do occur in very rare cases. Concentric narrowing 
of the field of vision is mentioned by Herschel {Berl. hi. Woch , 
1883, p. 456) and Jessop {Jahr. f. Aug., 1886, p. 248). Neuritis is 
described by Bouchut {Gaz. des Hop., 1873, p. 302), Galezowski 
{Jahr. f. Aug., 1881, p. 401) and Nagel {ib., 1884, p. 328) ; the lat- 
ter has noticed color disturbance and concentric narrowing of the 
visual field. 

Among the rare sequelse may be mentioned abscesses of the orbit 
and cheek (Romiee, Jahr.f. Aug., 1879, p. 425, and Heyl, ib., 1880, 



392 THE EYE IN RELATION TO DISEASE. 

p. 419), also inflammation of the left lachrymal gland, together with 
swelling of the parotid, cervical and submaxillary glands and acute 
catarrh of the middle ear, in a boy of nine years, after pharyngeal 
diphtheria (Lindner, Wien. med. Woch., 1891, p. 683). 

Renal disease is a not infrequent sequel of diphtheria, even 
apart from so-called scarlatinous diphtheria. The renal affection 
may later involve the eye. [Extension of inflammation to the middle 
ears is not to be omitted from an inventory of the rather frequent 
sequelsB of diphtheria. — Ed.] 

Influenza. 

Rampoldi, Annal. di Off.^ XIX, I; Eversbusch, Muench. med. 
Woch., 1890, No. 6; Pflueger, ib., No. 27; Greeff, ib.; Gutmann, 
^6., No. 48; Adler, Wien. hi. Woch., 1890, No. 4; Galezowski, 
Eec. d'Ophth., 1890, No. 2; Badal and Fage, Arch. d'Ophth., 
1890, p. 136; Hillmanns, Diss. Bonn, 1890; Ehrlich, Diss. Breslau, 
1892. 

All the complications and sequelae which are found in acute in- 
fectious diseases in general are also observed occasionally in influ- 
enza. Very few occur, however, with any considerable degree of 
frequency, if we bear in mind that among the many millions of cases 
within the last few years everything of a striking and phenomenal 
character has probably been reported. 

Hypersemia of the conjunctiva is extremely frequent and may be 
regarded as one of the symptoms of the disease. Conjunctivitis with 
mucous or muco-purulent secretion is much rarer, and severe cases 
are extremely rare. Croupous (Pflueger) and even diphtheritic 
(Coppez) forms have been observed occasionally, and Rampoldi re- 
ports the occurrence of subconjunctival abscesses. When follicles 
were already present in the conjunctiva, the conjunctivitis appeared 
as so-called follicular catarrh. 

There is sometimes more or less oedema of the conjunctiva and 
eyelids, which may last a variable period. Hordeola are not rare. 
Unusually large ones are sometimes called abscesses, but recover 
without difficulty after perforation or incision. 

Mild and severe phlyctenular diseases of the conjunctiva and cor- 



POISONS AND INFECTIOUS DISEASES. 393 

nea have been reported, but, according to Greeff, they were not more 
frequent during the epidemics than at other times. 

Conjunctival hemorrhages, which I have seen in a number of 
instances, develop in a purely mechanical manner as a result of the 
coughing spells, especially if the vessels were already in a brittle 
condition. 

Dacryo-cystitis will probably develop only in those cases in which 
stenosis or chronic inflammation of the lachrymal sac has already 
existed. 

Influenza is one of those infectious diseases in which eruptions 
of herpes are not infrequent; in Hamburg, herpes labialis was ob- 
served in twenty-five per cent of the cases. Herpes febrilis was also 
comparatively frequent on the lids and cornea. In the latter locality 
it was described under various names, sometimes even as neuro -pa- 
ralytic keratitis (Novelli). Finzi {Centr. f. U. Med., 1890, p. 931) 
mentions herpes zoster of the eyelids. 

Neuralgias of the eye and surrounding parts were quite frequent. 
Ciliary neuralgia, tenderness of the eye on pressure, pain on move- 
ment, and a feeling of pressure behind the globe may begin during 
the brief prodromal stage and may continue long into the period of 
convalescence. They are often among the most characteristic symp- 
toms. The pain and tenderness on moving the eye were so frequent 
and pronounced that Eversbusch is inclined to assume a change in 
the muscles themselves. In my opinion this was mainly a symptom 
of disease of the mucous membrane in the auxiliary cavities of the 
orbit, whence the inflammatory irritation extended to the periosteum 
of the orbit and the origins of the muscles. A similar affection of 
the frontal sinuses gave rise to the not infrequent supraorbital neu- 
ralgias. 

If we take into account the enormous number of cases of influ- 
enza, all other ocular complications and sequelae are extremely rare. 
They are, in great part, embolic processes due to secondary or mixed 
infection. The inflammation-producers found in such conditions 
have been the ubiquitous pyogenic staphylococci and streptococci, 
very often the diplococcus pneumoniae. The affections in question 
exhibit no symptoms which are characteristic of influenza. Bennet 



394 THE EYE IN RELATION TO DISEASE. 

{Lancet, Feb. 8th, 1890) calls special attention to the frequency of 
pysemic processes after influenza. 

Among uveal affections, hj^persemia of the iris is said to have 
been frequent. Plastic iritis was seen by Rampoldi, Delacroix {Arch, 
f. Aug., 1891, p. 127) and Gutmann, recent vitreous opacities by 
Eversbusch and Gillet de Grandmont {Bee. d'Ophth., 1890, No. 2). 
A number of plastic, purulent uveal inflammations, similar to those 
occurring after meningitis, were observed by Hosch {Coi^resp. f. 
Schweiz. Aerzte, March 1st, 1890), Nathanson {Petersb. med. Woch., 
1890, p. 213) and myself. Similar cases are reported by Laqueur 
{Berl. kl. Woch., 1890, No. 36; double embolic iridocyclitis), Ram- 
poldi, Badal and Fage. Eversbusch reports a panophthalmia due 
to staphylococcus pyogenes aureus, Rampoldi a similar case starting 
from necrosis of an old leucoma. Inflammations of Tenon's capsule, 
with or without suppuration, are reported by Fuchs, Greeff and 
Schapringer (New York Med. Rec, June 14th, 1890). 

Non-septic embolism of the central artery of the retina is reported 
by Hosch (one case) and Coppez (three cases). Hemorrhages into 
the eye are nowhere mentioned and are certainly extremely rare. 
Magnus {Forts, d. Med., 1891, p. 118) observed a so-called retinitis 
proliferans after influenza, and Gutmann reports a hemorrhage into 
the vitreous. 

There have also been orbital suppurations of an undoubted embolic 
character (Wicherkiewicz, Internat. kl. Rundschau, 1890, No. 8, 
and Borthen, Mon. f. Aug., March, 1891). 

Influenza has often excited an outbreak of acute attacks of glau- 
coma (Eversbusch, Adler, Gradenigo, Rampoldi, Stuffier, Badal and 
Fage). I have also seen a bilateral attack of acute glaucoma in an 
individual who had exhibited symptoms of glaucoma for some time 
in one eye, while not the slightest abnormality had been noticed in 
the other. I also observed an acute relapse of a serous iritis. There 
have been no reports of the recovery of an inflammation of the eye 
under the influence of influenza. 

Among diseases of the optic nerve, Denti {Arch. f. Aug., 1891, p. 
67) observed three cases of pronounced neuritis. Novelli {Bollet. di 
Ocul., XIII, p. 5) and Koenigstein {Wien. med. Bldt., XIII, 9), 



POISONS AND INFECTIOUS DISEASES. 395 

each one case; Lebeau {Ophth. Bee, Oct., 1891) double neuritis 
which recovered entirely; Vignes {Annal. d'Ocul., 115, p. 211) a 
neuritis of the left side with blindness, one week after influenza, and 
terminating in recovery w^th V=^. Partial or complete atrophy of 
the optic nerve as the result of so-called retrobulbar neuritis is re- 
ported by Bergmeister (Wien. hi. Woch., 1890, p. 201), Hansen 
(Centr. f. Aug., 1891, p. 120), Stoewer {3Ion. f. Aug., 1890, p. 
118), etc. 

Central disorders of vision hardly ever occur, apart from the 
visual hallucinations and illusions in influenza psychoses. Hill- 
mann observed yellow vision, possibly of central origin. Scintillat- 
ing scotoma is mentioned quite often, bat hardly appears to have been 
more frequent than in those who did not suffer from influenza. An- 
other remarkable sympathetic affection is reported bj^ Bock {lion. f. 
Aug., 1890, Dec), viz., that the eyelashes became w4iite immediately 
after influenza. Colley {Deutsch. med. Wocli., 1890, No. 35) ob- 
served Basedow's disease after influenza. 

Apart from blepharospasm, affections of the muscles are rare. 
The most frequent was unilateral and bilateral paresis of accommoda- 
tion, usually beginning suddenly, of a variable course, and some- 
times associated with disturbance of speech and deglutition, as in 
diphtheria. A few other cases of muscular paralysis have also been 
reported, viz., paralysis of the superior rectus (van derBergh, Annal. 
d'Ocul., 1890, p. 79; Badal and Fage), abducens paralysis (van der 
Bergh, I.e., Coppez, Badal and Fage, Valude, Annal. d'OeuL, 1890, 
Jan., Rampoldi), coincident paralysis of the levator palpebrse and 
superior rectus (Stoewer, I.e.), bilateral paralysis of accommodation 
with ophthalmoplegia externa (Uhthoff, Deutseh. med. Woeh., 1890, 
No. 10), double total ophthalmoplegia externa without implication 
of the levator palpebrse superioris (Gayet, JaJir. f. Aug., 1876, p. 
351), complicated unilateral ophthalmoplegia (Gutmann, I.e.), polio- 
encephalitis superior and inferior, and anterior descending poliomye- 
litis with fatal termination (Goldflam, Neurol. Centr., 1891, p. 162), 
etc. 

Renal affections and even acute hemorrhagic nephritis were quite 
frequent, but no mention is made of their effects upon the eye. 



396 THE EYE IN RELATION TO DISEASE. 

Among the rare phenomena are acute inflammation of the left 
lymphatic gland (Lindner, Wien. med. Woch., 1891, No. 16) and 
temporary blindness after epistaxis in a child of seven years (Sedan, 
Recueil d'Ophth,, March, 1890). 

Nervous disorders of vision, weakness of accommodation and the 
like, are occasionally very obstinate, corresponding with the often 
very protracted convalescence. 

Whooping- Cough. 

Conjunctivitis and epiphora are frequent in the prodromal stage. 
Photophobia and mydriasis often indicate the transition from the 
catarrhal to the convulsive stage {Deutsch. med. Woch.^ 1891, p. 
768). 

The violent coughing spells may produce hemorrhages into the 
eye. They are found most frequently beneath the bulbar conjunctiva, 
and are absorbed in from one to three weeks. 

Hemorrhages into the lids, with or without conjunctival hemor- 
rhages, are not uncommon. They are also absorbed without leaving 
a trace. 

Orbital hemorrhages, unless extensive, are usually not noticeable 
for several days, when the extravasated blood appears beneath the 
conjunctiva, in the eyelids and adjacent parts. Small hemorrhages 
are harmless ; large ones, which are rare, produce exophthalmus. 

Cerebral hemorrhages give rise to corresponding general and 
local symptoms, for example, hemianopsia, as in Silex's case (Berl. 
kl. Woch., 1888, p. 841). But this is evidently not a pure case, be- 
cause the disorder of vision occurred in a girl of seven years, three 
months after the whooping-cough and immediately after the admin- 
istration of two doses of morphine. On the other hand, whooping- 
cough may exhibit violent cerebral symptoms, such as disorders of 
vision, aphasia, paralysis, etc., which cannot be attributed to hemor- 
rhages (Troitzky, Jahr. f. Kinderh., XXXI, 3, p. 291). This cate- 
gory includes cases of sudden double blindness with intact reaction 
of the pupil, normal ophthalmoscopic appearances, and without albu- 
min in the urine (Alexander, Deutsch. med. Woch., 1888, p. 201; 
Jacoby, New York med. Woch., 1891). As in ureemic amaurosis 



POISONS AND INFECTIOUS DISEASES. 397 

(which may also occur in pertussis), the blindness may be preceded 
by headache and vomiting, and is probably due to slight meningitis 
of the convexity. Meningitis is not a very rare complication of 
whooping-cough and occasionally leads to optic neuritis with or with- 
out termination in total or partial atrophy and corresponding impair- 
ment of vision. The disease of the optic nerve may appear under the 
symptoms of an ischsemia, retrobulbar neuritis, or retrobulbar hem- 
orrhage. 

Knapp (Arch. f. Aug. u. Ohr., Y, 1, p. 203) observed bilateral 
blindness from retinal ischsemia, whitish optic nerve and narrow 
vessels, as in quinine poisoning. Vision gradually improved, but 
the case terminated fatally at the end of six weeks. 

According to Loomis, blindness in pertussis occurs almost exclu- 
sively in those who die later of pneumonia. Jacoby (I.e., Case I) 
observed sudden maximum mydriasis and immobility of the pupil, 
together with double optic neuritis and merely quantitative percep- 
tion of light; recovery in a very short time. In Alexander's (I.e.) 
Case 2, there was double neuritis with termination in partial atro- 
phy; a similar case is reported by Callan (Jalir. f. Aug., 1884, p. 
388). Landesberg (ih., 1880, p. 283) observed hemorrhage into the 
optic nerve with termination in atrophy ; in one case he saw obliter- 
ation of the two upper branches of the retinal artery of one eye, in 
another case subluxation downward of the right lens, as the result of 
violent coughing. 

Muscular paralyses also occur, either as the result of hemorrhages 
into the nuclear region, the nerve roots or the nerve trunks, or as 
the result of meningitis. Central (conjugate) disorders of the mus- 
cles may also occur in both ways. Rosenblatt (Jahr. f. Aug., 1883, 
p. 314) reports dilatation of one pupil, paralysis of the motor oculi 
with and without facial and acoustic paralysis, unilateral ptosis and 
paralysis of the opposite upper extremity, etc. 

Phlyctenular affections of the conjunctiva and cornea also occur 
after whooping-cough. Like other infectious diseases which ap- 
pear between the ages of two and four years, it is not infrequently 
the exciting cause of internal squint, especially in children who are 
predisposed to it by refractive errors. 



398 THE EYE IN RELATION TO DISEASE. 

Mumps. 

This is accompanied not infrequently by conjunctivitis, occasion- 
ally by epiphora, oedema of the lids, chemosis of the conjunctiva (from 
compression of the vessels of the neck, according to Hatry). The 
enlargement of the parotid is sometimes accompanied or followed 
by enlargement of the lachrymal glands. There is more or less acute 
enlargement of these glands, terminating in resolution. Cases of 
this kind are reported by Rider (Jahr. /. Aug., 1873, p. 471), Schroe- 
der {Mon. f. Aug., 1891, Dec), Seeligsohn {ib., 1891, Jan)., Gordon 
Norries. A more chronic case of swelling of the lachrymal and 
parotid glands is reported by Fuchs ("Beitr. z. Aug.," 1891, 3) ; an 
excised piece of the former exhibited the structure of lymphoma. 
In parotitis of the left side, Burnett {Jahr. f. Aug., 1886, p. 313) no- 
ticed on the right side considerable swelling of the orbital tissue 
with exophthalmus, mydriasis, paralysis of accommodation, swelling 
of the lids and double vision. The ophthalmoscope showed distended 
retinal veins. During an epidemic of mumps in the garrison at 
Lyons, Hatry (ib., 1876, p. 374) noticed, in ten cases, varying grades 
of congestion and inflammation of the retina and optic nerve, with 
corresponding impairment of vision. 

Hirschberg (Centr. f. Aug., 1890, p, 77) and Scheffel {ib., p. 
136) report cases in which the lachrymal gland, but not the parotid, 
was enlarged. It is doubtful whether these cases may be called 
mumps of the lachrymal gland, in the sense that they have the same 
cause as epidemic parotitis, although in Scheffel's case the submax- 
illary and sublingual glands were also enlarged. 

The rare sequelae of mumps correspond to those of other infectious 
diseases. Tolon {Jahr. f. Aug., 1883, p. 466) reports unilateral optic 
neuritis, terminating in atrophy and blindness ; there were also cere- 
bral symptoms. The primary cause was evidently a complicating 
meningitis. Schiess (18. Jahresber. , p. 3) observed metastatic irido- 
cyclitis which necessitated enucleation; "the iris was remarkably 
thickened, had a peculiar medullated structure, and its vessels were 
very large." Boas {Mon. f. Aug., 1886, p. 273) reports a muscular 
paralysis, a paresis of accommodation after mumps. The causal 



POISONS AND INFECTIOUS DISEASES. 399 

connection of Adler's {Centr. f. Aug., 1889, Nov.) three cases of 
subepithelial keratitis appeared to be very doubtful. 

Pest and Yellow Fever 

often lead to affections of the eye, but they need not detain us here, 
because they exhibit no characteristic features. 

Beri-Beri. 

In beri-beri or kakke, the eye muscles are often attacked in a 
characteristic fashion. The facial, motor oculi, abducens and trochle- 
ar is nerves may take part in the spasms and paralyses. The face 
and lids also take part, in many cases, in the initial oedema of the 
disease. 

Laurengao (Jahr. f. Aug., 1872, p. 219) saw a number of cases 
of atrophy of the optic nerve, and also an attack of glaucoma excited 
by beri-beri. The amblyopia mentioned by Da Costa Alvarenga 
(^6., 1881, p. 325) was probably diplopia due to paralysis of ocular 
muscles. 

Kessler (i&., 1889, p. 506) repeatedly observed contraction and 
insufficient filling of the retinal arteries, white sheaths around the 
arteries and veins, and a whitish and bleached papilla. The same 
writer {Centr. f. d. med. Wiss., 1891, p. 760) found anatomically, in 
two cases, oedematous changes in the retina and optic nerve, with 
dilatation of the peri-choroidal and scleral lymph spaces, and to a less 
extent of the optic nerve sheaths. There was moderate interstitial 
optic neuritis. 

Vertige Paralysant. 

This affection (Gerlier's disease) is a peculiar infectious malady 
which occurs in cowherds or in individuals who sleep in cow-stables 
(Eperon, Rev. med. de la Suisse Eomande, 1887, No. 1; 1889, No. 
1; Haltenhoff, Prog. Med., 1887, No. 26). The chief symptoms are 
dulness, exhaustion, amblyopia and occasionally diplopia with nor- 
mal ophthalmoscopic findings, ptosis, paresis of the flexors of the fin- 
gers (which are used in milking), attacks of vertigo, etc. From 
1874 to 1886 Haltenhoff (I.e.) treated nine cases of this disease, 



400 THE EYE IN RELATION TO DISEASE. 

which usually runs a favorable course. Although the ophthalmo- 
scopic findings are generally normal, Eperon {I.e.) observed two 
cases of marked congestion of the papilla, associated, in one case, 
with peri -papillary hemorrhages. According to Mauthner the symp- 
toms point to the region of the muscle nuclei. It appears to me to 
be at least equally probable that there is a basal cause, a very mild 
form of basilar meningitis or meningeal oedema. Perhaps the whole 
process is merely an abnormal innervation of the vessels. In the 
latter event the ptosis would be sympathetic in origin. Anatomical 
lesions have not yet been discovered. 

Pellagra. 

This peculiar disease begins with intestinal catarrh ; it leads to 
erythematous swelling of those parts of the skin which are exposed 
to the air, and then to dark pigmentation of the integument. In 
about half the cases, cerebral symptoms and psychoses finally develop. 
The characteristic sign on the part of the eye is night-blindness, evi- 
dently as the result of the great impairment of nutrition. 

According to Tebaldi {Jahr. f. Aug., 1870, p. 374), ophthalmo- 
scopic findings are not uncommon. Among fifty cases he found con- 
gestion of the papilla eighteen times and occasionally sinuous and 
varicose veins ; the latter were seen particularly in obstinate relapses. 
In eleven cases the papilla was ansemic and pale and the vessels nar- 
row. Stroppa {ib., 1872, p. 363) saw two cases of atrophy of the 
optic nerve. Neusser {ib., 1887, p. 303) reports diplopia and ambly- 
opia. According to Rampoldi {ib., 1885, p. 318), the most frequent 
eye symptoms in pellagra, apart from torpor retinse, are retinitis 
pigmentosa, atrophy of the optic nerve, disappearance of the choroidal 
pigment, then marantic ulcers and necroses of the cornea, opacities 
of the lens and vitreous. These symptoms do not warrant any con- 
clusion with regard to the nature of the disease. 

The disease is generally attributed to the ingestion of spoiled 
maize, and Lombroso claims to have produced the symptoms by ad- 
ministration of the tincture of such maize to poorly nourished indi- 
viduals. In this event pellagra would not be an infectious disease, 
but a chronic ptomaine poisoning. Several writers have found a 



POISONS AND INFECTIOUS DISEASES. 401 

definite bacillus which is said to be the cause of the spoiling of the 
grain, and this would then constitute the indirect cause of the dis- 
ease. 

Malaria. 

This is probably due to an animal parasite, the plasmodium ma- 
larise. 

In malarial attacks certain eye symptoms may form part of the 
attack or may even be a substitute for it. A characteristic feature is 
their periodical occurrence (this is also true of other diseases in ma- 
larial regions) and the rapid curative action of quinine. Neuralgias, 
especially the supraorbital form, occasionally the ciliary form, are 
very frequent. Muscular paralyses (ptosis, Adelsheim, Jahr. f. 
Aug., 1888, p. 385) and spasms (spasm of accommodation, Stilling, 
lb., 1875) have also been noted. Amblyopia (central) and even com- 
plete blindness, without ophthalmoscopic findings or loss of the pupil- 
lary reaction to light, have been observed as part of severe attacks 
and also in latent malaria (Dutzmann, Wien. med. Presse, 1870, p. 
511; Yachi, Neurol. Centr., 1888, p. 634). Blindness has also been 
observed after the attack (Koslowsky, Jahr.f. Aug., 1878, p. 281); 
it was associated with congestion and oedema of the papilla, and 
probably peripheral in character. 

Peunoff (Centr. f. Aug., 1878, p. 881) states that the pupil is al- 
ways dilated during the paroxysms, more markedly in the hot than 
in the cold stage. When the dilatation is pronounced, it is still rec- 
ognizable fifteen to eighteen hours after the attack. Otherwise it 
disappears in five to six hours. There was also congestion of the 
retina and optic nerve (as always happens in mydriasis) . 

Hilbert {Centr. f. Aug., 1881, May) describes conjunctival ca- 
tarrh as a rare form of latent intermittent fever ; it occurred four 
times in the tertian type, was attended with splenic enlargement, 
and was cured by quinine. Meisburger {Jahr. f. Aug., 1883, p. 
299) also mentions conjunctivitis, Adams {ih., 1881, p. 318) iritis, 
Selueck {ih., 1889, p. 504) five cases of plastic iritis, Dubelir {ih., 
1883, p. 299) blindness with exophthalmus ; intermittent strabismus 

has also been described {Jahr.f. Aug., 1870, p. 462). Baas {Mon. 
26 



402 THE EYE IN RELATION TO DISEASE. ^ 

/. Aug., 1885, p. 240) reports a case of blue vision which appeared 
every other day between 10 and 12 A.M., and was cured by quinine. 

Retinal hemorrhages may occur in severe cases at the beginning 
of the disease, but they are more frequent in later stages. Accord- 
ing to Mackenzie (Jahr. f. Aug., 1877, p. 215) these hemorrhages 
are more frequent in the quotidian than in the tertian type. Ac- 
cording to Peunoff (I.e.) many attacks are complicated with conjunc- 
tivitis and ciliary injection, and even iritis may develop. Severe 
attacks are attended by coma and cerebral symptoms, among which 
double cortical blindness is occasionally found. 

According to Sulzer {Arch. d^Ophth., 1890, p. 193), hypersemia 
of the disc, slight obscuration of the fundus, photophobia and " see- 
ing sparks" are observed in twenty per cent of the cases during and 
between the attacks. These cases exhibited a marked predisposition 
to macular affections, similar to those observed in looking at an 
eclipse of the sun, but the prognosis is favorable. 

As in other infectious diseases, a series of complications is found 
after the malaria has lasted a long time. According to Sulzer (I.e.) 
these include, 1, neuritis, usually bilateral, in severe cases with pig- 
mentation of the papilla, in eight per cent with termination in atro- 
phy of the optic nerve; 2, diffuse vitreous opacities; 3, multiple 
retinal hemorrhages; 4, sudden and permanent blindness. Other 
complications which have been observed are : iritis (Peunoff) , sup- 
purative choroiditis (Peunoff , 7. c. , Landesberg, Jahr. f. Aug., 18$0, 
p. 324), chorio-retinitis (Poncet, Annal. d^Ocul., p. 201), unilateral 
retrobulbar neuritis with large central color scotoma (Uhthoff, 
Deutsch. med. Woch., 1880, p. 303), two cases of unilateral atrophy of 
the optic nerve without preceding neuritis (Bull, Jahr.f. Aug., 1877, 
p. 213). Macnamara {Brit. Med. Journ., March 8th, 1890) reports 
a paresis of the external and inferior recti, Uhthoff {I.e.) anabducens 
paralysis. Bagot {Ann. d^Oe., 1891, Nov.) attributes two cases of 
double soft cataract to malaria. 

A deposit of pigment is found not infrequently in the fundus after 
malaria of long standing. Such deposits are undoubtedly due to 
pigment emboli, as the result of gradually developing melansemia or 
formation of pigment flakes in the blood. In the retina these emboli 



POISONS AND INFECTIOUS DISEASES. 403 

are comparatively harmless, but in the cerebral cortex they may give 
rise to serious symptoms. 

Poncet {I.e.) found on autopsy changes in the retina, and partic- 
ularly in the choroid, much more often than the ophthalmoscopic 
findings indicated. These changes included oedema, hemorrhaged, 
lesions of the walls of the vessels and thromboses, small inflammatory 
foci with and without pigment, etc. He is inclined to attribute the 
larger proportion of the cases of malarial amblyopia and amaurosis 
without findings to this " chorio-retinitis palustris," but this is prob- 
ably true of very few cases. The majority are undoubtedly of central 
origin, due to similar changes in the occipital cortex or to pigment 
emboli in that locality. Hemianopsia is also observed occasionally 
(De Schweinitz, Med. Neivs.lS'dO, No. 27; Peunoff, oTa/ir. /. Aug., 
1883, p. 301) . The latter observed in his own person an attack (last- 
ing twenty-four hours) of complete blindness, aphasia, left hemiplegia 
and anaesthesia. In two comatose patients, he observed double com- 
plete blindness with aphasia and paralyses which disappeared in a 
few days. The central disorders of vision, which occur at the very 
onset, and the retinal hemorrhages of the same period, must be re- 
garded as septic, the result of ptomaine poisoning. 

Cortical blindness may also be ursemic in character, inasmuch as 
renal diseases and their sequelae are found quite often in chronic 
malarial poisoning. A " scorbutic terminal stage" sometimes devel- 
ops, and may be manifested by hemorrhages in all parts of the visual 
apparatus. Quinine may also give rise to disorders of vision, but 
these are peripheral in character {vide p. 351). [Keratitis as the 
result of malaria is not infrequent, and presents features which are 
more or less typical. It attacks by preference the epithelium and 
superficial layers, is non-suppurative ; ulcerations are superficial. It 
is chronic in duration. There is often anaesthesia of the surface. 
The opacity is apt to run in streaks, yet may present itself in patches. 
One will find marked tenderness of the supra-orbital nerves as they 
pass out of the orbit, which is the most valuable pathognomonic sign, 
and when concurring with the conditions described indicates the 
absolute necessity of quinine in effective doses as an adjuvant to local 
treatment. — Ed . ] 



404 THE EYE IN RELATION TO DISEASE. 

Eruptions of herpes are frequent in intermittent fever. It also 
appears upon the cornea and has been described under the most vari- 
ous names (p. 253). Night blindness, torpor retinae, is not infre- 
quently one of the most striking symptoms of malarial cachexia. 

Trichinosis. 

This disease is also due to an animal parasite. The oedema of 
the lids, which often appears at the very beginning, is occasionally 
important in diagnosis. It is only in severe cases that the trichina 
emigrates into the external eye muscles, and the smooth internal 
muscles always escape {vide p. 269). 

The chronic infectious diseases which require consideration are 
syphilis, tuberculosis, scrofula and leprosy. Prior to the discovery 
of their specific bacilli, the two latter diseases were regarded as 
"constitutional affections," and thus form a suitable transition to the 
latter. 

Syphilis. 

Vide Alexander, "Syphilis u. Auge," Wiesbaden, 1888, 1889; 
Schubert, "Ueb. syphilit. Augenleiden," Berlin, 1880; Manz, Jahr. 
f. Aug., 1872, p. 220, etc. 

The acquired form of syphilis will first be discussed. The eye 
may be the point of entrance of the infection, and the hard chancre 
may be found upon the lid or its free margin and upon the conjunc- 
tiva. The most frequent localization is the inner angle of the eye, 
upon the caruncle, where a small loss of substance is apt to occur 
from rubbing; next in frequency stands the lower lid and its free 
border, and not very rarely the palpebral conjunctiva. Hard chan- 
cre of the bulbar conjunctiva is extremely rare (Rona, Mon. f. prak. 
Dermat., 1891, p. 462) . A case of chancre of the cornea has also been 
reported (JuUien, "Mai. vener.," p. 585). Like all diseases of the 
eye which are due to rubbing the eye, hard chancre is much more 
frequent on the right side. 

The induration is usually very hard and extensive, and lasts a 
long time. A hard spot may be distinctly felt even at the end of a 
year and a half. Recovery is usually quite complete, and the indu- 



POISONS AND INFECTIOUS DISEASES. 405 

ration is associated merely with swelling of the lids, epiphora, che- 
mosis, conjunctivitis, etc. Partial entropium and trichiasis are not 
infrequent terminations (Krelling, Viertelj. f. Dermat. u. Syph., 
XV, p. 1). 

The swelling of adjacent lymphatic glands may also be very pro- 
nounced ; they may extend from the lobe of the ear to the acromion 
and supraclavicular fossa. From the glandular enlargements in 
syphilitic primary lesions, Lavergne and Perrin concluded that the 
lymphatics of the inner part of the eyelids pass to the submaxillary 
glands, those of the outer half to the glands of the parotid region and 
the pre- auricular glands. 

Hard chancre of the lids might possibly be mistaken for epithelial 
cancer. The age of the patient will usually, though not always, de- 
cide the diagnosis. In two cases I have seen chancroid at the inner 
angle of the eye in young people of twenty years. The enlargement 
of the glands is found in both diseases, so that sometimes the appear- 
ance or absence of secondary syphilitic manifestations must decide 
the diagnosis, unless a microscopical examination can be made. 

The integument of the lids is also involved in the eruptions of 
the early period of the disease. According to Michel, this is especially 
true of roseola or acnelike eruptions. When they affect the border 
of the lids, they may give rise to loss of the eyelashes. Ulcerative 
eruptions, even rupia, are not uncommon upon the lids (Alexander, 
I.e., p. 12). Eruptions upon the conjunctiva are very rare (Gut- 
mann, Deutsch. med. JVoch., Feb. 16th, 1888; Sichel, Jahr. f. 
Aug., 1880, p. 292). 

Syphilitic iritis generally appears at this early stage, commonly 
associated with eruptions, but sometimes at an early period. At the 
beginning it is unilateral and does not differ from plastic iritis due 
to other causes. At a later period the other eye is often affected and 
relapses are also frequent. Syphilis is by far the most frequent 
cause of iritis. According to some statistics three-fourths of all iri- 
tides are syphilitic, according to others (Arlt) only one-fourth. 

It is only in fifteen to twenty per cent of the cases that the iritis 
appears in a manner which is characteristic of syphilis (iritis gum- 
mosa, condylomatosa, papulosa). Yellow or dirty orange-colored 



406 THE EYE IN RELATION TO DISEASE. 

nodules appear in the tissues of the inflamed iris; they are surrounded 
by a narrow red zone and rarely exceed 2-3 mm. in diameter. Their 
favorite location is the vicinity of the border of the pupil, especially 
below, but they are found occasionally in other parts. A small hypo- 
pyon is not very uncommon ; it is sometimes attended with a striking 
subsidence of the previously violent pains. The little nodules may 
disappear entirely under suitable local and general treatment; they 
usually leave a broad synechia and often a discolored atrophic patch. 
The term iritis papulosa is probably more correct than iritis gum- 
mosa, in view of the stage of syphilis in which iritis is generally 
found, but there is really only a quantitative difference between a 
syphilitic papule and a gumma. Larger, confluent gummy tumors 
of the iris occasionally appear in the later stages of severe syphilis. 
They may fill the entire chamber and their growth may lead to loss 
of the eye. These are usually associated with severe inflammatory 
changes in the other parts of the uvea. 

Sometimes there is merely a nodule-like thickening of the tissue 
of the iris, but even in the apparently diffuse, non-papular iritis the 
microscope shows little nodules due to arteritic changes, proliferation 
of epitheloidal cells and accumulations of round cells. 

Iritis gummosa, papulosa, or condylomatosa will suffice for a pos- 
itive diagnosis of syphiljs. At the most it might be mistaken for an 
abscess of the iris, but this is prevented by the previous history (for- 
eign body in the iris). Certain granulomata are easily distinguished 
from the yellowish-red syphiloma by their gray or grayish-red color. 

I have recently seen typical iritis papulosa as the first and sole 
secondary symptom, three weeks after a hard chancre; rapid recov- 
ery followed antisyphilitic treatment. Two months later syphilitic 
eruptions of a severe ulcerating form appeared upon the skin. 

'No part of the eye and adjacent structures is spared during the 
further course of syphilis, apart from the lens, which is only involved 
secondarily. 

Syphilis is manifested either by inflammations, mainly intersti- 
tial, of any part of the visual organ, but chiefly of the uvea and retina, 
the nerves and meninges, or by specific new formations. The latter 
are composed at first of a granulation-like, later by a necrobiotic 



POISONS AND INFECTIOUS DISEASES. 407 

tissue (syphiloma, gumma) which may develop in any region. They 
may be circumscribed like a tumor, single or multiple, or diffused 
over a large area, especially at the base of the brain. 

A common feature of all syphilitic diseases is a peculiar affection 
of the small arteries (arteritis syphilitica), which leads to narrowing 
and finally occlusion of the vessels. This lesion may also occur sep- 
arately, without inflammatory phenomena or specific new growths. 
In the latter event the symptoms are insignificant, although they 
result occasionally in a cerebral hemorrhage ; in young people this is 
always suggestive of syphilis. While the inflammations and gummy 
neoplasms may subside, the arteritic changes only resolve in part, 
and the consequent impairment of nutrition may give rise, particu- 
larly in the nervous system, to certain diseases (tabes, etc.), usually 
of an atrophic character, which are much less frequent in non-syph- 
ilitics. 

So long as the inflammation or neoplasm remains interstitial, 
complete restoration is possible; destroyed nerve fibres or ganglion 
cells cannot be destroyed. 

As a general thing, the diffuse superficial inflammations belong 
to the early, the gummous lesions to the later stages of syphilis, but 
both forms are often observed at the same time. The coalescence of 
the small foci (which are also present in the former variety) into 
larger, tumor-like or more diffuse new formations, merely shows the 
diminished power of resistance of the tissues. 

Aside from the ordinary plastic form, iritis may also appear in 
the serous form, as an asthenic or cachectic inflammation, or, on the 
other hand, it may occur, when the inflammation is very acute, as 
iritis gelatinosa or fibrinosa. As in all syphilitic inflammations, 
hemorrhagic forms are comparatively rare. The remarks made con- 
cerning the iris are also true of the ciliary body and choroid, which 
are more or less implicated in iritis. Cyclitis and choroiditis ma}^ 
develop in every possible degree of violence and duration. The in- 
flammation may be diffuse or focal (disseminated choroiditis) ; the 
two forms can only be differentiated with the ophthalmoscope, on 
account of the implication of the pigment epithelium in the dissem- 
inated form. The microscope shows that the inflammation is mainly 



408 THE EYE IN RELATION TO DISEASE. 

focal in both forms, but specific changes in the arteries are also widely 
diffused. 

In the mild forms, choroiditis occurs in the ordinary disseminated 
variety, with very slight disturbance of vision, and may come to a 
standstill at any stage. It does not differ from the variety due to 
other causes. Certain varieties, such as that associated with numer- 
ous small atrophic spots surrounded by a pigmented zone (choroiditis 
areolaris) are perhaps more frequent in syphilitics than in others. 
According to Graefe and Foerster, syphilitic choroiditis dissem- 
inata is more frequent at the posterior pole of the eye ; according to 
Galezowski, it occurs chiefly at the equator. Flocculi in the vitre- 
ous, associated with disseminated choroiditis, arouse the suspicion 
of syphilis, but there are undoubted syphilitic affections without these 
flocculi. 

More frequently the choroidal attacks are severe and are compli- 
cated by numerous and dense vitreous opacities. The ophthalmo- 
scope may show disseminated foci, but the process is usually (iiffuse, 
i.e., the pigment epithelium is not notably affected at the start. The 
attacks do not always yield promptly to anti-syphilitic treatment, 
and may lead to loss of sight, either by implication of the iris (occlu- 
sion of the pupil and increased tension) or by detachment of the re- 
tina. As a general thing, the severe forms belong to the late stages 
of syphilis and may be very painful, especially when the ciliary body 
is profoundly involved. In part, however, these are not true syphi- 
litic affections, but must be regarded as sequelae in an individual 
weakened by a previous infectious disease; in such cases antisyphi- 
litic treatment is useless. 

As a matter of course the retina is very often, if not always, 
affected in these choroidal inflammations, so that it would be more 
correct to speak of a chorio-retinitis. Hitherto it has been the cus- 
tom to call the disease choroiditis when the ophthalmoscope showed 
changes in the pigment epithelium, and retinitis when these changes 
are absent. 

At the start, the clinical symptoms are usually insignificant and 
of a general character, such as " seeing sparks, " floating spots, occa- 
sionally subjective colored vision. These symptoms are evidently 



POISONS AND INFECTIOUS DISEASES. 409 

due to the irritation of the outer layers of the retina by the diseased 
choroid (Schenke) . Even when the disturbance of vision is more 
pronounced, — cloudy vision to complete, usually positive scotoma 
(generally central, in rare cases even annular) — it is explained in the 
main by the impaired function of the outer layers of the retina. 
Torpor and anaesthesia retinae, micropsia, etc. , are sometimes the 
most striking symptoms. 

The ophthalmoscopic appearances depend upon the implication of 
the pigment epithelium. We find choroiditis disseminata in every 
possible degree, with pigmentation of the retina similar to, but much 
more irregular than typical retinitis pigmentosa ; or there is merely 
more or less dense and extensive opacity of the retina. 

In the former case, anatomical examination shows numerous 
points of adhesion between the choroid and retina, at which the pig- 
ment emigrates into the latter. The retina exhibits irregular patches 
of cellular infiltration and also the appearances of typical specific 
arteritis. In a case examined by me, which presented the clini- 
cal symptoms of annular scotoma, the changes in the pigment 
epithelium were visible with the ophthalmoscope over the entire 
fundus. 

The second form, in which the opacity of the retina predominates 
and the changes in the pigment epithelium are insignificant, is ob- 
served chiefly in the region of the macula lutea. It has been called 
central relapsing retinitis (von Graefe), because it is only in this 
locality that it produces notable disorder of sight. Diffuse opaque 
patches are not uncommon in other parts of the fundus, but a periph- 
eral amblyopic spot in the monocular field of vision must be very 
large in order to produce any striking loss of sight. In the macula 
lutea and fovea centralis every impairment of vision at once becomes 
noticeable. 

The initial clinical sj^mptoms are vague and point to irritation or 
loss of function of the outer layers of the retina. They include dis- 
torted vision, photopsise, photophobia, hemeralopia, micropsia, "see- 
ing sieves or gratings" (this indicates destruction of individual groups 
of rods and cones) , etc. These symptoms progress gradually or quite 
suddenly into a central, often very dense, and usually positive sco- 



410 THE EYE IN RELATION TO DISEASE. 

toma, which is seen as smoke or mist. Diffuse implication of the 
entire retina may produce complete blindness. 

The ophthalmoscope shows a diffuse gray opacity of the fundus 
over a greater or less area, occasionally more marked along the ves- 
sels. This opacity must be attributed, at least in part, to dust-like 
opacity of the vitreous. The optic nerve is usually reddened and 
there is some venous congestion of the fundus ; hemorrhages into the 
retina are extremely rare. 

If the disease attacks mainly the macular region, the opacity is 
here most dense, but is not infrequently overlooked at the start, when 
the examination of this region without atropine is difficult. The 
retinal vessels in the macula are noticeably dilated and often appar- 
ently increased in number, because small, otherwise invisible vessels 
can be seen on account of the congestion. The specific arteritis may 
be seen as whitish -yellow sheaths around the arteries, and we often 
find in the affected parts of the retina small, yellowish or brownish, 
roundish spots grouped like bunches of grapes (Ostwalt, Berl. hi. 
Woch., Nov. 5th, 1888, and Hirschberg, ^&., Nov. 12th, 1888). 

Apart from the specific arteritis, which may also exist indepen- 
dently of retinitis, the microscope shows very little in the retina. 
More or less extensive choroidal changes are always demonstrable. 

The disease may begin in the first six months, but more frequently 
in the second, third, or fourth years after infection ; it may be uni- 
lateral or bilateral. It is generally very obstinate and often relapses. 
The final termination is quite favorable in the majority of cases, al- 
though permanent impairment of vision, even yellow atrophy of the 
optic nerve and complete blindness, may be left. There may also be 
a new formation of connective tissue upon the inner surface of the 
retina and extending into the vitreous (retinitis prolif erans) . This 
hardly ever happens except when hemorrhages have occurred, and 
these are rare in syphilitic affections. 

As a matter of course there is every possible transition between 
the two forms of disease just described. The more severe the dis- 
ease, the more dense are the vitreous opacities, and the greater the 
likelihood that shrinking of the vitreous, detachment of the retina 
and phthisis bulbi will set in. I have found that typical central reti- 



POISONS AND INFECTIOUS DISEASES. 411 

nitis is met with chiefly in j^oung people, and is rare beyond the age 
of forty. Disseminated choroiditis, with more or less abundant vit- 
reous opacities, is more frequent in older people. Foerster (/.c, p. 
191) appears to have had the same experience. 

Larger gummous neoplasms also grow from the choroid, iris and 
ciliary body, although rarely from the latter (Mauthner, Woinow, 
Alt). It is usually impossible to secure their resolution without 
causing destruction of the eye. 

Inflammations of the sclera are frequent as a part of extensive 
syphilitic uveitis, and may recover or may leave scleral staphylo- 
mata. They are rare as an independent disease in syphilis and do 
not always yield promptly to specific treatment, so that their syph- 
ilitic nature may remain doubtful. Gummata may also start from 
the sclera ; more frequently they start from the uvea and involve the 
sclera secondarily. 

Syphilitic disease of Tenon's capsule is very rare; it produces 
the same symptoms as tenonitis from other causes and yields to anti- 
syphilitic treatment. In acquired syphilis, specific disease of the 
cornea is disproportionately rare. Diffuse interstitial keratitis, 
which is so frequent and characteristic in congenital syphilis, is ob- 
served only in rare cases and at a late period in acquired syphilis. 
In the majority of cases it should be regarded as a sequel, because 
anti-syphilitic treatment usually exerts no influence upon it. It runs 
essentially the same course as the hereditary syphilitic variety, but 
may merely affect a part of the cornea or give rise to opacities at the 
edges (Hock, Wien. Klinik, 1876). 

Mauthner (Zeissl's "Lehrb. d. Syph.") describes a true keratitis 
punctata in syphilis. Opacities as large as the head of a pin come 
and go, with or without ciliary injection, in the various layers of 
the cornea; they never grow larger and never lead to suppuration. 
The disease is extremely rare. Alexander (I.e., p. 45) has seen a 
similar condition associated with true iritis. 

Under the term gumma of the cornea, Denaire describes roundish 
gray diffuse opacities, associated with iritis (probably the form just 
mentioned), and Magni describes small opaque patches at the ex- 
treme periphery of the cornea. I have observed a grayish-yellow 



412 THE EYE IN RELATION TO DISEASE. 

infiltration, about 3 mm. in diameter, situated beneath transparent 
epithelium, about 2 mm. from the rim of the cornea, to the outside 
and above. This had developed in an elderly individual three years 
after syphilitic infection. Antisyphilitic treatment had no very 
striking effect, but the infiltration slowly disappeared, leaving a 
grayish, distinctly depressed patch without any development of ves- 
sels. This may very readily have been a gumma ; and the imperfect 
effect of mercurial treatment may have been due to the fact that it 
was situated in a non-vascular tissue. 

Conjunctival catarrh, congestion and the like are often found in 
syphilis without any real relation to this disease. They are some- 
times produced, however, by undoubted syphilitic affections of the 
lids, lachrymal organs, etc. The observations of Goldzieher {Centr. 
f. Aug., 1888, p. 103) and Sattler {Prag. med. Woch., 1888, No. 12) 
are the only ones reported concerning a specific, trachoma-like disease 
of the conjunctiva, which yields only to anti-syphilitic treatment. 
The direct connection with syphilis of the " recurrent conjunctival 
hypersemia," of which four cases were described by Alt {Cqntr. f. 
Aug., 1890, p. 373), is somewhat doubtful. 

True gummata also occur upon and beneath the conjunctiva 
(Trousseau, Ann. de Dermat. et Syph., IX, No. 7, two cases in the 
ninth and twelfth months in severe syphilis ; Estlander, Mon. f. Aug., 
YIII., p. 259, etc.). They may also develop in the lachrymal carun- 
cle (Taylor, Jahr. f. Aug., 1875, p. 452). As a general thing, how- 
ever, the gummata of the conjunctiva start from the tissue of the 
upper lid, particularly from the cartilage. They may develop even 
during the first year of the disease, grow to the size of a pea or a bean, 
and generally ulcerate rapidly and cicatrize. If the inferior maxil- 
lary and pre-auricular glands are greatly swollen, the gumma may 
present a close resemblance to the initial lesion. A non-gummous 
tarsitis, an acute enlargement of the cartilage without ulceration, 
also occurs in the early stages of syphilis and disappears after proper 
treatment. 

Even the lachrymal glands, which were long regarded as exempt, 
have been found to be gummatous in rare cases, or to be attacked by 
an interstitial inflammation (Streatfield, Albini, Adler and Alexan- 



POISONS AND INFECTIOUS DISEASES. 413 

der, Z.C., p. 36). The tumor produced by their enlargement rapidly 
subsides under specific treatment, while they previously resisted all 
therapeutic efforts. 

Syphilitic disease may also appear in the orbit and its bony walls. 
Gummy periostitis leads to caries and necrosis, especially at the rim 
of the orbit. Periostitis of the deeper parts necessarily produces 
symptoms of tumor : protrusion of the globe away from the tumor, 
impairment of mobility toward the side of the tumor, more or less 
impairment of vision according to its position (especially at the optic 
foramen and superior orbital fissure), anaesthesia of the conjunctiva 
and cornea with its sequelae (neuro-paralytic keratitis), neuralgias 
and paralyses. In addition there are signs of inflammation : swelling 
of the lids, chemosis, more or less conjunctivitis and, at a later period, 
signs of orbital suppuration and the formation of fistulae. The symp- 
toms are not characteristic of the syphilitic origin of the lesion. The 
diagnosis depends upon the previous history and the results of speci- 
fic treatment. 

The tear passages are often attacked in the form of dacryocystitis, 
dacryo-cysto-blennorrhoea, and stenosis. The disease extends in most 
cases from the nasal mucous membrane. The bony walls of the 
lachry mo-nasal canal are not infrequently involved. This results 
frequently in cicatricial, even bony occlusion, and the prognosis is 
thus materially aggravated. 

Lesions of the cranium and its contents are probably the most 
serious manifestations of the disease. Arteritis obliterans may cause 
sudden elimination of entire vascular tracts in the brain and lead to 
hemorrhage and softening. This is very significant of syphilis when 
the patient is young and does not suffer from cardiac disease. Gummy 
growths may also develop. They appear as superficial infiltrations, 
particularly at the base of the brain, inclosing the optic nerve, chiasm, 
tractus, motor and sensory nerves ; but also upon the convexity, where 
they give rise to cortical symptoms, such as hemianopsia, aphasia, 
Jacksonian epilepsy, etc. They may also occur as tumors, either sin- 
gle or multiple, in any part of the brain or its meninges. The symp- 
toms may advance rapidly or slowly {vide page 138) and with more 
or less irritation and inflammation of surrounding parts. 



414 THE EYE IN RELATION TO DISEASE. 

Syphilis is often manifested by a multiple gummy basilar neuritis, 
or every possible disease of the brain and cord may be simulated. A 
characteristic feature of brain syphilis is the striking variability of 
the symptoms, so that, for example, Oppenheim {Berl. kl. Woch., 
1887, p. 666) regards "oscillating" bitemporal hemianopsia as a cri- 
terion of syphilis of the base of the brain. Under suitable treatment, 
apparently impossible recoveries are sometimes effected; on the 
other hand, apparently mild symptoms may prove very obstinate. 

Eye symptoms are very common in cerebral syphilis, but we will 
discuss only two, viz., diseases of the optic nerve and paralyses. 

Central and peripheral affections of the optic nerve are very fre- 
quent tokens of syphilis. They are usually secondary, as, for exam- 
ple, the neuritis of uveal and retinal diseases, which generally recov- 
ers, but occasionally terminates in yellow atrophy ; we find also neuri- 
tis due to meningitis or gummy growths, and terminating in recovery, 
partial or total atrophy; choked disc from cerebral gumma, simple 
pressure atrophy or retrobulbar neuritis in diseases of the skull and 
orbit, etc. Tabetic atrophy of the optic nerve should no longer be 
included among syphilitic diseases, even though it develops in an 
individual who was formerly syphilitic. 

The optic nerve may also be affected in a more independent man- 
ner and, as a rule, at a relatively early period, viz., between the 
eighth and twentieth months. In this optic neuritis, which may be 
single or double, isolated or associated with neuritis of other basilar 
nerves, the microscope discloses the specific character of the affection 
by the arteritis and interstitial gummy processes. These are found 
not only in the nerve, but also in the chiasm and tractus, so that 
there may be various peripheral disorders of vision. The prognosis 
is comparatively favorable, the more so, the earlier the disease 
begins after infection. Later the secondary diseases of the optic 
nerve predominate, and the nervous elements, which cannot be re- 
placed, are more apt to be destroyed. 

Badal (Arch. d'Ophth., VI, p. 301) found 139 cases of disease of 
the optic nerve and 144 paralyses among 631 cases of ocular syphilis. 

Syphilitic paralyses of eye muscles may also be due to various 
causes. The muscle itself may be diseased, specific neoplasms in the 



POISONS AND INFECTIOUS DISEASES. 415 

orbit (especially at the superior orbital fissure) may affect the nerves 
and muscles, neoplasms at the base of the skull may compress the 
basilar nerves; growths within the brain ma3'iDJure the motor nerve 
roots and nuclei, or, if situated in the corona radiata and cortex, may 
give rise to conjugate deviations and paralyses. In all these cases 
the paralyses are usually combined with other evidences of syphilis. 
Isolated paralyses of the eye muscles are not infrequently the first 
symptoms of syphilis. They are due either to neuritis and perineu- 
ritis of the nerve roots and at the base of the brain, or they are nu- 
clear in origin; other causes are exceptional. 

Although every muscle is occasionally paralyzed in syphilis, cer- 
tain combinations are especially frequent. In about three -fourths of 
the cases the motor oculi is affected, in about one-fourth the abducens, 
the trochlearis in only one to two per cent, and the facial with equal 
rarity. Paralysis of the two latter nerves is usually combined with 
paralysis of the motor oculi or abducens. Perhaps a half of all paraly- 
ses of the ocular muscles are syphilitic in origin. Indeed, every 
spontaneous ocular paralysis or ophthalmoplegia necessitates a differ- 
ential diagnosis with regard to syphilis. 

An especially frequent form in s^'philis is unilateral ophthalmo- 
plegia interna, or paralysis of the sphincter of the pupil and of ac- 
commodation. According to Alexander, three-fourths of such cases 
are syphilitic, according to Uhthoff only one-fourth. We can easily 
understand the fact that syphilis attacks these two nuclei separately 
when it is remembered that the condition is due to arteritis, that the 
nutritive territory of the third ventricle is different from that of the 
aqueduct of Sylvius, and that the vessels, like those of the retina, are 
end-arteries (Cohnheim) . 

On the whole, syphilitic paralj^ses of the eye muscles are found in 
the later stages of the disease, rarely in the first six months. They 
may develop rapidly or slowly, are usually obstinate, and recover 
very slowly, in many cases not at all. Those which recover have 
no tendency to relapse. Naunyn observed seventy per cent of recov- 
eries. According to this writer, there is no hope of recovery if evi- 
dences of improvement do not appear after vigorous treatment for two 
weeks. 



416 THE EYE IN RELATION TO DISEASE. 

Paralyses may also occur at a very late period, even after syph- 
ilis has long been cured. In this event they often exhibit a different 
character. They appear and disappear rapidly, often relapse, and 
are not really syphilitic, but are the forerunners and symptoms of 
cerebral and spinal affections (tabes, multiple sclerosis, general pare- 
sis, psychoses, etc.). 

These diseases of the nervous system may also be observed years 
after the paralyses. Basilar, and particularly nuclear, paralysis in- 
dicates syphilitic disease of the arteries in the brain. The disease of 
the vessels leads to such a predisposition of the central organs that, 
even after the syphilis is cured, comparatively insignificant influ- 
ences will give rise to the diseases in question. 

In syphilitic coma, which occurs with or without warning symp- 
toms (headache, vertigo, convulsions, sudden blindness, etc.), the 
symptoms of cortical paralysis are associated, according to Althaus 
{Deutsch. med. Woch., Feb. 3d, 1887), with those of irritation of 
the pons and medulla oblongata, i. e. , the pupils are narrow and do 
not react, and the eyes are deeply sunken. This would differentiate 
the condition from alcoholic and ursemic coma, in which the pupils 
are large. In coma after opium poisoning and pontine hemorrhage, 
the pupils would be still narrower. It is doubtful, however, whether 
the combination described by Althaus is really constant in syphilitic 
coma. Moreover, the other forms of coma may also occur in syphili- 
tics. 

The diabetes which occurs occasionally in syphilis — usually as 
the result of new-formations or inflammation at the floor of the fourth 
ventricle — will hardly ever give rise to an affection of the eye, on ac- 
count of its usually temporary character. Such an effect may be 
produced, however, by syphilitic renal diseases. The latter develop 
in early syphilis in an acute, subacute, or more chronic form, as in 
scarlatina, and may also give rise to ursemic amaurosis. At a later 
period we find only chronic interstitial changes (contracted kidneys, 
sometimes associated with gummy deposits and waxy changes), 
which are the most frequent causes of retinitis and neuro-retinitis 
albuminurica. 

Congenital syphilis differs from the acquired form in many re- 



POISONS AND INFECTIOUS DISEASES. 417 

spects. The cases are always comparatively mild, because the severe 
ones die either in utero or soon after birth. Intra-uterine infection 
runs its course much more rapidly than extra-uterine infection, and 
the foetus often dies at an early period from tertiary syphilis. Even 
in the new-born, acquired syphilis runs its course much more slowly 
than the intra-uterine variety. This, together with the development 
of primary and secondary symptoms, distinguishes the former from 
the latter. But with regard to the eye diseases, especially diffuse 
interstitial keratitis, which appear at a later period, I have been un- 
able to detect any difference between congenital syphilis and that 
acquired immediately after birth. 

Diseases of the eyes (even those which have run their course) are 
not infrequently congenital. They include affections of the uvea, in 
its broadest sense, from simple choroiditis disseminata (chiefly with 
numerous small, round spots with deeply pigmented areolae) and 
hardly noticeable impairment of vision, to the most severe plastic 
forms of uveitis and irido-choroiditis with occlusion of the pupils and 
its results. The secondary symptoms include cataract, staphylo- 
mas of various kinds, even passing into general pathological enlarge- 
ment of the eye, slowly progressive inflammations with temporary 
or permanent increase of tension, excavation of the optic nerve, de- 
tachment of the retina, etc. The cornea may also undergo paren- 
chymatous disease in utero, and result in more or less extensive, con- 
genital opacities, with or without vascular development. There may 
even be ulcerations of the cornea with their results, such as corneal 
staphyloma, anterior synechia, anterior polar cataract. Such corneal 
findings are extremely rare (in only one case have I seen congenital 
anterior polar cataract with the signs of former perforation of the 
cornea, as a symptom of congenital syphilis), while the}" are seen 
much more often as the results of extra-uterine disease (blennorrhoea 
neonatorum) . 

Another series of congenital diseases of the eye are the results of 
intra-uterine meningitis. To this category belong the majority of 
cases of congenital neuritis and post-neuritic atrophy of the optic 
nerve. 

Extra-uterine uveal diseases are also observed in congenital syphi- 

27 



418 THE EYE IN RELATION TO DISEASE. 

lis. They include choroiditis from the mildest to the most severe 
forms, with retinitis and pigmentation of the retina, usually with, 
more rarely without, opacities of the vitreous ; at a later period they 
give rise not infrequently to cataract, especially of the narrow striped 
or punctate variety. The coincidence of visible vitreous opacities 
with disseminated choroiditis is, in a measure, characteristic of its 
specific origin, but exceptions to this rule are quite frequent. More- 
over, choroidal affections of an asthenic type and iritis serosa in a 
perfectly non-characteristic form occur much more frequently in 
hereditary syphilis than in other conditions, although this is denied 
by various writers. 

Plastic iritis is rare in children, especially in the new-born; in 
the majority of the cases it is due to hereditary syphilis. Hutchin- 
son (Ophth. Hosp. Rep., VIII, p. 217) reports five cases of severe 
plastic iritis in children from one and one-half to eight years old, in 
whom every form of syphilis could be excluded. Gummata or pap- 
ules of the iris are very rare. Cases are reported by Alexander (Z.c, 
p. 196), Trousseau {Ann. de Dermat. et Syph., VI, p. 415), Watson 
(Ophth. Hosp. Rep., XI, 1, p. 65) and Liebrecht {Mon.f, Aug., 1891, 
p. 184) ; the last case is very doubtful. 

Diffuse interstitial keratitis (keratitis parenchymatosa, keratitis 
scrophulosa of Arlt) which is very characteristic of congenital syph- 
ilis, begins between the age of six years (rarely earlier) and the 
period of puberty. [I have seen cases at the age of eighteen and of 
thirty-two years. — Ed.] This disease does not occur exclusively in 
congenital syphilis, but this is true of such a large percentage of cases 
(according to Horner two-thirds, according to Mauthner four-fifths) 
that it alwaj^s rouses a lively suspicion of such a cause. Arlt for- 
merly denied any connection with congenital syphilis and called the 
disease keratitis scrophulosa, but later he receded somewhat from 
this position. In my own experience, an extremely large percentage 
have been due to syphilis. There is no doubt, however, that a series 
of cases occur in the non-syphilitic, but I have rarely observed it in 
pronounced scrofula. 

Diffuse interstitial keratitis may be the sole symptom of congeni- 
tal syphilis. More frequently, however, there are other evidences of 



POISONS AND INFECTIOUS DISEASES. 419 

syphilis, such as deformities of the skull, deafness, or other signs of 
meningitis, depression of the nose, arthritides and their sequelae, es- 
pecially in the knee-joint, enlargement of the glands, etc. According 
to Hutchinson, a peculiar formation of the teeth, which is most 
marked in the upper middle, permanent incisors (Fig. 20), 
is extremely characteristic of congenital syphilis ; and in fact WW 
this is true of a iar^e percentage of cases. The same con- 

° ^ ° Fig. 20. 

dition is observed not so very rarely, however, in children 
who do not exhibit any other evidences of congenital syphilis. This 
fact limits to a certain extent the diagnostic value of the malforma- 
tion of the teeth. In many cases the previous history of the parents 
furnishes the most certain proofs of congenital syphilis. It is not 
alone in feeble and anaemic children that syphilitic disease of the 
cornea is observed, but, in rare cases, in those who are well-developed 
physically and mentally. Diffuse interstitial keratitis, when it oc- 
curs after the period of puberty, is usually a relapse and generally 
runs a more severe course than the original disease. 

Interstitial keratitis is an emigration keratitis which starts from 
one spot in the rim of the cornea (more rarely from several spots) and 
gradually traverses the entire membrane. In reality, therefore, the 
disease is uveal in character. Hence, severe cases are complicated 
so often with lesions of the choroid, especially its anterior part, and 
of the iris and ciliarj" body. In other cases the interstitial keratitis 
is secondary to extensive choroidal disease. 

In congenital syphilis the walls of the orbit are found diseased 
not infrequently, particularly its free border and the walls of the 
lachrymal sac and lachry mo-nasal canal. Usually we have to deal 
with periostitis or caries, which exhibit no characteristic features, 
much more rarely with true gummatous disease. Gummy tumors 
develop occasionally in the orbit, upon the periosteum, in the lids, 
etc., but they are very rare. 

Diseases of the bony walls of the tear passages often lead to acute 
and chronic inflammations of the lachrymal sac and lachrymo-nasal 
canal with their sequelse, especially to bony stenoses and adhesions. 

Other symptoms on the part of the eyes which are due to heredi- 
tary syphilis are extremely rare. A few cases of muscular paralysis 



420 THE EYE IN RELATION TO DISEASE. 

have been reported (Graefe, Arch, f, Ophth., I, 1, p. 433, paralysis 
of the left motor oculi; Mackenzie, quoted by Alexander, Z.c, p. 
207, double abducens paralysis and ptosis ; Lawford, Ophth. Rev., 
April, 1890, two cases of incomplete paralysis of the motor oculi) . To 
these I can add a case of isolated paralysis of the right pupil, which 
lasted two years, in a girl of nine years. The father was syphilitic 
and, strange to say, also suffered from unilateral mydriasis ; a sister, 
aged seven years, suffered from diffuse interstitial keratitis, and the 
two remaining sisters had died, with specific symptoms, soon after 
birth. Barlow {Lancet, 1877, No. 8) reports alopecia of both eye- 
brows, and Scheffelt (Arch. f. Aug., XXII, 4) observed disease of 
the retinal veins which were converted, in part, into white bands, 
as the first symptom in a man of eighteen years. 

With few exceptions all these hereditary syphilitic affections of 
the eye are to be regarded as occurring in syphilitic infection which 
has run its course, i.e., as analogous to the post-syphilitic diseases 
of the nervous system. Hence, specific treatment is useful only in 
the first years of childhood. In later years it may even act injuri- 
ously by producing weakness of the general system. [I have seen a 
case of hereditary syphilitic keratitis which occurred in a young man 
aged twenty-eight, for the first time, was successfully treated by hot 
fomentations and specific remedies, and who also passed successfully 
through another attack two years later with the help of the same 
treatment. — Ed.] 

Tuberculosis and Scrofula. 

In tuberculosis the eye may serve as the point of entrance of in- 
fection, usually from the conjunctiva (tuberculosis or lupus of the 
conjunctiva). The intact conjunctiva is never infected by tubercle 
bacilli ( Valude) . There must always be a loss of substance, whether 
due to injury or to ulceration. Ulcers then develop with a more or 
less extensive, infiltrated base. The base is often covered with abun- 
dant, bleeding granulations. The microscope reveals tubercular 
nodules in the latter and in the edges of the ulcer, and miliary nod- 
ules are not infrequently visible to the naked eye. The process ex- 
tends to the adjacent tissues and may attain considerable dimensions, 



POISONS AND INFECTIOUS DISEASES. 421 

especially in the lids. After a while the glands in front of the ear or 
below the lower jaw become swollen. A trachoma-like tubercular 
infection of the conjunctiva may also develop. 

In many cases conjunctival tuberculosis long remains the sole 
localization. Early destruction of the neoplasm may then lead to re- 
covery. In other cases the conjunctiva is attacked secondarily, either 
by propagation from the vicinity (skin, lachrymal sac, nose, intra- 
ocular tubercular neoplasms), or by means of emboli. The latter 
method is probably the least frequent. 

When miliary nodules are not visible to the naked eye, the diag- 
nosis is assured by the demonstration of tubercle bacilli in bits of the 
tissues. Bacilli have also been found in the tears (Amiet, Diss. 
Zuerich, 1887; Burnett, Arch. f. Aug., XXIII, p. 336). 

A distinction between tuberculosis and lupus of the conjunctiva can no 
longer be made. Although the latter is a local affection, the presence of tuber- 
cle bacilli decides the diagnosis. Accroding to Neumann, the tubercle under- 
goes cheesy degeneration, the lupus nodule does not. Inoculation of lupus ma- 
terial into the anterior chamber produces tuberculosis (Trousseau, Arch. d'Opth., 
1889, Nov. -Dec. ; Pagenstecher and Pfeiffer, Berl M. Woch., 1883), butaccord- 
ing to Parinaud (Gaz. hebd., 1884), this remains local and does not become 
general as in inoculation with tubercular material. The chief difference in 
such cases appears to me to reside in the nutrient medium, i.e. , in the individual 
attacked. In tuberculosis, the products of disassimilation offer very little or no 
resistance to the proliferation of the bacilli, in lupus they diminish their vital 
activity to a notable extent. As a matter of course, a sharp boundary cannot be 
drawn and every possible transition is met with. Nor is it impossible that lupus 
may be converted at a later period into typical tuberculosis. 

Tangl {Centr. f. Aug., 1891, p. 14) found tubercle bacilli in a 
chalazion and therefore regards it as a tubercular new-formation. 
This opinion has met with decided opposition (Weiss, Mon. f. Aug., 
1891, p. 206; Deutschmann, "Beitr. z. Aug.," II, p. 109). Without 
denying the possibility that rare cases of tubercular disease of the 
lids may for a time present the appearances of chalazion, typical 
chalazion has not the slightest clinical or anatomical connection with 
tuberculosis. 

At the start, acute tuberculosis of the lid may look like a large 
hordeolum and may not exhibit the characteristic changes until a 
late period. Yet no one will regard hordeolum in general as a tuber- 
cular new-formation. 



422 THE EYE IN RELATION TO DISEASE. 

In the further course of tuberculosis every part of the organ of 
sight may be invaded. There may be tumor-like new-formations in 
the eye and in the cerebral organs, or superficial, diffuse inflamma- 
tions of a tubercular character. In the latter event the uvea is very 
of tea, the retina much less frequently, attacked; usually the tubercle 
nodules are only visible with the microscope. The latter may or 
may not be associated with tubercular meningitis. 

In much rarer cases the tubercles are visible with the ophthal- 
moscope. Single or multiple, whitish-yellow, round patches, over 
which the retinal vessels pass, are found in the fundus. They are 
very rarely surrounded by a striking pigmented zone, and this may 
be important in dijfferential diagnosis. The individual nodule may 
become smaller and even disappear, but it usually grows, coalesces 
with adjacent ones, and projects more and more distinctly from the 
fundus. Plastic, purulent inflammatory processes in the retina and 
vitreous, detachment of the retina, etc., develop at a later period. 
These make further observation with the ophthalmoscope impossible 
and terminate in loss of the eye, generally after perforating ex- 
ternally. 

On the whole, choroidal tubercles which are visible with the oph- 
thalmoscope belong to the terminal stage of tuberculosis and often 
develop shortly before death. This diminishes their diagnostic 
value, because the diagnosis is no longer doubtful at that period. 

Tubercles also form in the anterior parts of the choroid, in the 
ciliary body and iris, but only the latter are visible from the start. 
Terson {Arch. d^Ophth., X, p. 7) claims to have successfully re- 
moved tubercle of the iris. According to Michel, hemorrhages from 
the ciliary body may be the first symptom of tuberculosis in this 
region. 

Tubercles in the choroid, which are occasionally bilateral (Haugg, 
Diss. Strasburg, 1890), may apparently constitute for a long time 
the only manifestation of tuberculosis. In such cases large nodules 
may form and perforate externally. They can only be distinguished 
with the microscope from gummy nodules in the same locality. 

Tubercles rarely develop primarily in the sclera, and very rarely 
in the cornea (Panas and Vassaux, Jahr. /. Aug., 1885, p. 341; Roy 



POISONS AND INFECTIOUS DISEASES. 423 

and Alvarez, ih.j Rachet, These de Paris, 1887). In the latter event 
there is evidently infection of corneal ulcers from tuberculosis of the 
conjunctiva. 

The optic nerve, tractus, chiasm and central parts are also affected 
very often in tuberculosis, either directly, or by inflammation and 
the formation of tumors in the vicinity, or by " remote action." Vis- 
ual disorders with and without ophthalmoscopic findings, spasms, 
paralyses, sensory disturbances, etc., are frequent symptoms of tu- 
bercular meningitis or of tumor-like new-formations ; the latter are 
especially apt to be situated in the anterior fossa and the region of 
the chiasm. 

Tubercular processes within the orbit are rare, but its bony walls, 
and occasionally those of the lachrymal passages, are often diseased 
in the form of periostitis and caries. In the large majority of cases 
these must be attributed to syphilis or tuberculosis. 

Superficial, diffuse diseases of the membranes of the eye, especially 
of the uvea, also occur in tuberculosis. The bacilli are not uniformly 
diffused, but give rise to very small, scattered nodules which are apt 
at a later period to coalesce. According to Wagner (Miiench. med. 
Woch., 1891, No. 15), tubercular iritis constitutes fifty per cent of 
all iri tides, but this figure is much too high. Wagner has appar- 
ently included all cases of so-called iritis serosa, but the miliary foci 
of the latter affection are merely accumulations of more or less de- 
generated round cells. 

Iritis attended by the formation of nodules often appears to be 
of a tubercular nature. These nodules are grayish-red in color 
(gumma nodules are yellowish-red), of the size of a pin's head or 
larger, are multiple, and often come and go for a long time. A sim- 
ilar condition is observed occasionally in the absence of all signs of 
inflammation of the iris (lymphoma?). 

It is probable that, under the influence of the products of the ba- 
cilli circulating in the blood, inflammations maybe produced if some 
other factor is added, as, for example, a trauma. In this event the 
products of the inflammations will naturally be free from bacilli, and 
yet, with a certain degree of propriet}^, may be called tubercular, 
i.e., they have developed under the influence of tuberculosis. We 



424 THE EYE IN RELATION TO DISEASE. 

must assume this in a series of inflammations, especially of the dif- 
ferent sections of the choroid (also in many other infectious diseases). 

So-called scrofula has been recognized as latent tuberculosis since 
the demonstration of tubercle bacilli in the cheesy glands. It may 
be converted into typical tuberculosis by means of any influence 
which causes the bacilli to enter the general circulation. 

The term scrofula is applied to a condition in which, during the 
course of protracted inflammations of the mucous membranes (par- 
ticularly of the respiratory organs, but very often of the digestive 
canal), the corresponding lymphatic glands suffer tubercular infection 
from losses of substance and undergo cheesy degeneration. The 
patients are sometimes vigorous individuals, and in such cases recov- 
ery may be effected by calcification of the degenerated glands (or by 
operative removal), after recovery of the disease of the mucous mem- 
brane. But the majority of the patients are in a more or less debili- 
tated condition, and usually the term scrofulous is applied only to 
them. 

Such individuals exhibit a decided tendency to eczematous (phlyc- 
tenular) affections of the integument of the lids, the conjunctiva and 
cornea. Arlt applies the term scrofulous conjunctivitis to eczema- 
tous disease of the conjunctiva, but, strange to say, he does not apply 
this term to the analogous disease of the cornea but to diffuse inter- 
stitial keratitis. 

A decided tendency to phlyctenular disease of the conjunctiva 
and cornea is also observed in other asthenic conditions, especially 
those left over after protracted and severe diseases, for example, dur- 
ing convalescence from infectious diseases. 

On the other hand, one or more outbreaks of eczema may appear 
upon the conjunctiva and cornea in otherwise healthy individuals to 
whom the term scrofulous would not be proper. It is therefore pref- 
erable to drop the term conjunctivitis scrofulosa, etc., and to employ 
the term which is applied to the corresponding disease of the skin, 
such as eczema, or, if this is not considered desirable, phlyctenulse 
(vesicles) . 

The term " scrofulous" was formerly much abused. It meant cod- 
liver oil, etc., and often entire neglect of the disease of the skin or 



POISONS AND INFECTIOUS DISEASES. 425 

eyes, although suitable local treatment is all important. This often 
causes surprisingly rapid recovery of the glandular enlargements 
when they are due not to bacillary, but merely to inflammatory 
swelling. 

In " scrofulous" diseases of the eye the local treatment of the re- 
spiratory mucous membrane, especially of the nose, is the most im- 
portant for the purpose of preventing the endless relapses. 

The term " scrofulous" was formerly applied to those normal but 
feeble individuals who, as the result of improper nourishment, have 
lost to a certain degree their power of resistance to external in- 
fluences. In children this is manifested chiefly in the integument 
and certain mucous membranes, in the form of chronic catarrhs at- 
tended by ulceration and eczemas. The term scrofula was employed 
especially w^hen numerous lymphatic glands became enlarged on ac- 
count of infection from the ulcers, either from the reception of infec- 
tious germs or of the products of decomposition. At the present time 
the term scrofula, from an anatomo-pathological standpoint, is con- 
fined to those cases in which the glands undergo cheesy degeneration 
as the result of the absorption of tubercle bacilli, while from a clini- 
cal standpoint the term is stiU used in many cases in w^hich the en- 
largement of the glands is due to less harmful influences. 

Leprosy. 

Fide Bull and Hansen, Jalir. f. Aug., 1873, p. 218; Pedraglia, 
Mon. f. Aug., X, p. 65. 

For a long time this disease appeared to be confined, in Europe, 
to a few small localities, but in recent times it has evidently spread, 
for example, in the Baltic provinces. It is due to a micro-organism 
which resembles the tubercle bacillus very closely. Prior to its dis- 
covery leprosy was regarded as a constitutional disease. 

Unlike the infectious diseases hitherto considered, this has a very 
long period of incubation, on the average four to five years, some- 
times apparently ten to fifteen years; not infrequently the period of 
incubation is shorter. The primary lesion is comparatively insig- 
nificant and is usually overlooked. According to Eklund infection 



426 THE EYE IN RELATION TO DISEASE. 

often takes place from inoculation into the conjunctival sac by means 
of towels {Jahr. f. Aug., 1879, p. 256). 

Lepra ansesthetica and tuberosa differ merely in the amount of 
development of the specific new-formation, which is a granulation- 
like tissue containing typical bacilli (with marked implication of the 
interstitial tissue of the nerves) , in a nodular or superficial form. Both 
forms occur in the tissues of the organ of sight. According to Lopez 
{Arch. f. Aug. , XXII, 2 and 3) , the eye is affected in half the cases, 
the eye with its appendages in all cases. 

Anaesthetic patches and nodules often develop in the eyebrows 
and lids ; the hairs fall out, the nodules grow to the size of a hazel- 
nut and disappear mainly through ulceration, rarely from central 
softening. Cicatricial ectropium of the lids may develop under either 
process. 

The nodules are situated in or beneath the skin ; they are accom- 
panied by cellular infiltrations, especially along the vessels. The 
secondary effects are : paralysis of the orbicularis palpebrarum, par- 
alytic ectropium, traumatic conjunctivitis and keratitis, pannus of 
the lower half of the cornea, iritis, etc. (Parinaud, Ann. d^OcuL, 
115, p. 140). According to Meyer numerous very small nodules are 
found in such cases of pannus. 

Anaesthesia of the cornea may result in neuro-paralytic keratitis. 
Bull and Hansen did not observe its development, despite anaesthesia 
of the trigeminus, even when flies wandered about the cornea and 
conjunctiva. 

We often find growths upon the conjunctiva, which spread to the 
cornea and also invade the interior of the eye. Eversion of the lids 
from the eye, interference with their closure, epiphora, etc. , may also 
be caused by the leprous connective-tissue tumors. The latter form 
round, hard, whitish, pale yellow or red, shining growths, which 
are not tender on pressure, and are situated at the rim of the cornea 
and beyond it. They are gradually lost toward the fornix, but ter- 
minate abruptly toward the cornea. The secretion is slight, and the 
nodules usually do not ulcerate. 

The adjacent cornea is cloudy, later it is entirely opaque or looks 
as if strewn with flour ; it may become very ectatic. 



POISONS AND INFECTIOUS DISEASES. 427 

The conjunctival nodules may grow more and more over the cor- 
nea. They may shrivel and soften, sometimes after the lapse of 
years. The usual termination is in shrivelling of the globe. 

Nodules may also develop in the deeper layers of the cornea ; there 
may also be simple punctate keratitis with or without iritis. 

Bacilli are often found in the tears, nasal secretion and fluid of 
the mouth (Besnier, "Sur la Lepre," Paris, 1887). 

According to Bull and Hansen, the sclera, unlike the uvea, is 
never attacked primarily and independently. 

In the nodular form, iritis may develop during the iSrst year ; in 
the anaesthetic form, it is usually secondary, due to corneal ulcers 
accompanying paralysis of the orbicularis. Acute iritis is almost 
always associated with vitreous opacities. More rarely there are 
nodules both in the iris and in the cornea. They are grayish in 
color, start from the periphery and are generally situated in the lower 
half of the iris. They may gradually fill the entire anterior cham- 
ber and cornea and produce staphyloma of the adjacent sclera. 
Small nodules in the iris may disappear spontaneously and then un- 
dergo several relapses. 

In many cases the iritis terminates in complete occlusion of the 
pupil, while cyclitis and cyclo-choroiditis may develop secondarily. 
Secondary opacity of the lens is also observed not infrequently. 

According to Bull and Hansen, iritis and irido-choroiditis are more 
amenable to treatment than corneal affections. These writers success- 
fully removed iris nodules by operation. 

It is not to be wondered at that hemeralopia is often present in 
the later stages of such a chronic disease. A scorbutic terminal 
stage is observed not infrequently, and may lead occasionally to 
hemorrhages into the eye. 



OHAPTEE IX. 
CONSTITUTIONAL DISEASES. 

The so-called constitutional diseases make up a category which 
is constantly growing smaller with the increase of our knowledge. 
Apart from the few congenital conditions (haemophilia) or develop- 
mental anomalies (chlorosis), they may be regarded as chronic dis- 
eases of uncertain origin. 

Some of the diseases formerly included in this category, such as 
scrofula, leprosy, and probably rheumatism, have been found to be 
chronic infectious diseases. Many are probably to be regarded as 
chronic diseases of various organs, with which they often exhibit 
great similarity, for example, with the condition in contracted kid- 
neys. To this class belong many forms of diabetes, particularly the 
severe forms (pancreas), Addison's disease (suprarenal capsules), 
Basedow's disease and myxoedema (thyroid gland) , leukaemia (spleen, 
lymphatic glands, medulla of the bones), etc. Other constitutional 
anomalies are, in the main, diseases of a special system, such as 
rachitis and osteomalacia of the osseous system, scurvy, amyloid and 
general atheromatosis of the vessels, gout of the joints, serous mem- 
branes and cavities. In all cases there are disturbances of respira- 
tion, digestion, absorption, or secretion. 

Certain of the constitutional anomalies also exhibit a great resem- 
blance to chronic infectious diseases, in so far as "specific" neo- 
plasms may develop, for example, in the tumor cachexia of malignant 
tumors and leukaemia. As no specific micro-organism has been found 
in these cases, we must assume that the tumor cells and the leukaemic 
leucocytes themselves play the part of the specific inflammation- 
producer. 

In a measure we may distinguish between quantitative and quan- 
titative constitutional anomalies. In the former there is an absence 



CONSTITUTIONAL DISEASES. 429 

of definite organic disease, while the latter receive from such disease 
their peculiar characteristics. The former exhibit in the eye, as in 
the rest of the body, mere symptoms of general weakness without 
visible anatomical findings: weakness of accommodation and con- 
vergence, retinal asthenopia, neuralgic pains on using the eyes, night 
blindness, often associated with xerosis of the conjunctiva {vide p. 
34), concentric narrowing of the field of vision, with paroxysmal 
loss of sight, especially as the forerunner of attacks of syncope, etc. 

Ancemia. 

The symptoms just mentioned are the only eye symptoms observed 
in pure cases of anaemia, cachexia and marasmus. It is only in very 
advanced cases that the papilla is notably paler and may even be 
chalky-white; the blood in the vessels is evidently lighter, but the 
color of the fundus is not changed appreciably. Pulsation of the 
retinal vessels is occasionally visible (Becker). 

A rather striking fact is the great frequency of congestion of the 
conjunctiva, also called dry catarrh, in anaemias of all kinds. One 
of its main causes is probably insufiicient sleep or insomnia. 

The eyeball and lids may be more or less sunken on account of 
wasting of the orbital fat, and this furnishes one of the characteris- 
tic peculiarities of the " marantic" facial expression. 

The arcus senilis is merely evidence of a local fatty degeneration 
of the corresponding parts of the cornea. It is only when it appears 
at an unusually early period that it possesses a certain significance 
in the diagnosis of "senium prsecox." 

Other eye symptoms in pure anaemia are more or less accidental 
complications. They are very numerous because anaemic conditions 
are observed so frequently. 

Spontaneous oedema of the lids, icteric color of the conjunctiva 
(slight haematogenous jaundice) and spontaneous hemorrhages (es- 
pecially into the retina ^), which occur in very advanced cases, consti- 

^ The retinal hemorrhages of pernicious anaemia are often converted, in the 
centre, into white patches. At first this was looked upon as a peculiar phenom- 
enon, but it is simply a process of absorption which often occurs in other non- 
septic hemorrhages. Vessel changes may be present or absent in pernicious 



430 THE EYE IN RELATION TO DISEASE. 

tute transitions to qualitative tissue changes and toxic phenomena. 
These give to the condition the character of pernicious anaemia, 
which is not necessarily fatal in all cases. Fraenkel {Deutsch. 
Arch. f. kl. lied., XX) has also described parenchymatous changes 
in the external eye muscles in such cases. They were pale and clay- 
colored, the transverse striation was absent in great part, the fibres 
were filled with j^ellow or brown pigment, or were finely granular. 
Some fibres were narrow and waxy. Neuritis, retrobulbar neuritis, 
atrophy of the optic nerves, etc., also occur under such conditions, 
especially when there has been considerable loss of blood. The 
ophthalmoscopic appearances sometimes resemble those of retinitis 
albuminurica, although the urine does not contain albumin. 

If the general disorder of nutrition is acute in its onset, a hemor- 
rhagic diathesis develops not infrequently. This is shown by spon- 
taneous hemorrhages without visible tissue changes in all parts of 
the body, including the eye and adjacent parts. These hemorrhages 
exhibit no unusual symptoms, and this is also true of the hemor- 
rhages of scurvy. A hemorrhagic nuclear paralysis (Cavalie, Jahr. 
f. Aug., 1879, p. 224) or neuritis (Lawford, Brit. Med. Journ., 
1882, II, p. 119) is observed occasionally in scurvy. It goes without 
saying that hemeralopia is frequent in scurvy. 

So-called marantic keratitis is a traumatic or desiccation keratitis 
which develops as the result of narcotic toxines and toxalbumins 
which are produced in the final stages. 

Plethora, Corpulence, Obesity. 

When these conditions produce eye symptoms they are similar to 
those found in anaemia. It is to be noted that in general obesity the 
eyelids (and the scrotum) are unaffected, and this gives the individ- 
ual a peculiar appearance. 

In the higher grades of plethora and corpulence, abnormal pro- 
ducts of disassimilation or excessive amounts of the normal products 
can be demonstrated, for example, increased amount of uric acid in 
the urine. This furnishes a transition to true gout. On the other 
hand, there is not infrequently a transition into qualitative constitu- 



CONSTITUTIONAL DISEASES. 431 

tional anomalies, particularly diabetes, so that it is sometimes diffi- 
cult to draw a line between these conditions. 

Schooler (Berl. kl. Woch., 1887, No. 52) observed three cases of 
corneal and conjunctival xerosis after a course of treatment for obe- 
sity. Excessive weakness, or even actual collapse, is not infre- 
quent and compels the observance of caution. 

The ansemic and marantic conditions may be regarded as equiva- 
lent to insufficient nutrition or absorption, the plethoric conditions as 
equivalent to insufficient respiratory activity with regard to the in- 
gested food. Hence the frequent shortness of breath in plethora, 
even in the absence of respiratory diseases, and the accumulation 
of imperfectly oxidized substances in the body (fats, uric acid) . This 
is true to a certain degree, and then pathological and toxic products 
of disassimilation appear. These give rise to anatomical changes in 
the tissues (necrobioses and inflammations) , particularly in the walls 
of the vessels. The latter are characteristic of the qualitative con- 
stitutional anomalies, although the}' may not occur for quite a long 
time. 

As a general thing, signs of quantitative disturbance of nutrition 
are alone present for a certain length of time, and even these may be 
very slight or almost entirely absent, despite the presence of abnor- 
mal products of disassimilation or the increase or diminution of nor- 
mal products. At a later period, toxic and inflammation-producing 
substances are created (auto-intoxication). These may give rise to 
tissue changes, even passing into hemorrhagic inflammation, or a 
narcotic action which may terminate in profound coma. Both effects 
are sometimes produced paroxysmally, with comparatively free inter- 
vals. Some of these constitutional conditions like diabetes and leukae- 
mia may present very active outbreaks. 

In the course of the constitutional anomalies there are very often 
secondary infections with all their sequelae, partly through the agency 
of inflammation and suppuration producers (pyaemia, erysipelas, 
etc.), which are everywhere present, partly through other bacilli, 
such as the tubercle bacillus. These secondary infections may ex- 
hibit peculiarities in their course on account of the modified nutrient 
medium offered by the diseased individual. The course of the sec- 



432 THE EYE IN RELATION TO DISEASE. 

ondary affection is usually more rapid and severe than in healthy in- 
dividuals. In other cases, however, there may be a certain immu- 
nity against different micro-organisms. This may even be confined 
to special organs. 

Chlorosis. 

Apart from the typical symptoms of exhaustion, slight grades of 
chlorosis produce no striking changes in the eye. At the beginning 
they correspond to the degree of anaemia and nutritive disturbance, 
which are always present at the same time. 

Despite marked ansemia, there are very often signs of congestion 
of the conjunctiva, such as a tired feeling, a sensation of sand in the 
eyes, of weight or roughness of the lids, etc. These are the signs of 
conjunctival asthenopia or so-called dry catarrh, and are relieved 
most effectually by diluted laudanum (5 : 10-15). 

In very severe cases of chlorosis there may be visible pulsation 
of the retinal arteries (Becker) , but this is confined, as a rule, to the 
optic papilla. This symptom is to be regarded as an evidence of 
considerable diminution of the arterial pressure. In other respects 
the ophthalmoscopic appearances are normal. 

The oedema of the skin, which is not uncommon in severe cases, 
is also observed upon the lids, particularly the lower lid. The optic 
nerve is pale, the retinal vessels narrow and filled with light-colored 
blood, a condition transitional to that of pernicious ansemia; hem- 
orrhages into the fundus are never observed. In such an event 
we would hardly be justified in regarding the case as one of pure 
chlorosis. 

A number of cases have been reported in which bilateral neuritis 
and neuro-retinitis, with or without hemorrhages and with or with- 
out whitish exudation in the retina, have been associated with chlo- 
rosis (Gowers, Jahr. /. Aug.^ 1880, p. 236; Herschel, ih., 1882, p. 
329; Eddison and Teale, ih., 1888, p. 530; Bitsch, Mon. f. Aug., 
1879, p. 144). In view of the rarity of these cases and the frequency 
of chlorosis, this association may be a mere coincidence. 

In several cases of severe chlorosis without any other demonstra- 
ble disease, I have observed whitish shining patches in the retina ; 



CONSTITUTIONAL DISEASES. 43^. 

they were mostly grouped around the fovea centralis in the well- 
known stellate shape of retinitis albuminurica. The remainder of 
the fundus was normal, and there was very little or no impairment, 
of vision. The affection was always unilateral, lasted more than six 
months, and, with improvement of health, finally disappeared with- 
out leaving a trace. The appearances were probably due to small 
foci of fatty degeneration in the nerve-fibre layer of those parts of 
the retina which are destitute of capillaries. Such cases are probably 
at the extreme boundary of pure chlorosis, the characteristic feature 
of which is the absence of anatomical changes in the tissues. 

Haemophilia. 

In rare cases this condition gives rise to hemorrhages into the 
organ of sight. Bramwell (Jahr. f. Aug., 1886, p. 307) reports a 
cerebral hemorrhage associated with eye symptoms, Priestley Smith 
(^6., 1888, p. 530) an orbital hemorrhage following an injury. Other 
eye symptoms are, in the main, those of " weakness of the eyes" as a 
part of the general condition of weakness. After profuse hemorrhages 
of haemophilia, the disturbance of vision may appear as amblyopia or 
amaurosis after loss of blood. (These patients are known as "bleed- 
ers.") In Grossmann's case {Arch. cVOphth., II, p. 122), a boy of 
fifteen years suffered, on the fifth day after violent epistaxis, from 
impairment of vision passing into complete blindness; complete 
atrophy of the optic nerves finally developed. 

Spontaneous hemorrhages into the lids and conjunctiva are not 
very frequent, and nothing has been reported concerning extravasa- 
tions into the interior of the eye. 

Addison^ s Disease. 

This affection is not infrequently associated with degenerative 
and inflammatory diseases of the nervous system, particularly of the 
sympathetic (Flenier, Wiesbadener Congress, 1891). 

The eyelids and face are often deeply discolored, the conjunctiva 
hardly ever, but the latter is often more or less jaundiced. Huber 
(Deutsch. med. Woch., 1885, No. 38) saw a patch upon the conjunc- 
tiva; Schroetter (Wien. med. Blaett., 1886, 'No. 21) saw patches on 
28 



434 THE EYE IN RELATION TO DISEASE. 

the gums, buccal mucous membrane and sclera; Feuerstein (^6., 
1888, No. 35) saw several dark-brown patches, as large as millet- 
seeds, upon the conjunctiva. 

The organ of sight also takes part in the general symptoms of 
weakness and is occasionally attacked as the result of complications, 
for example, renal diseases. It is well known that bronzing of the 
skin is not always connected with disease of the supra-renal capsules 
— and also that disease of these organs does not always produce bronz- 
ing. 

Diabetes. 

Vide Leber {Arch. f. Ophth., XXI, 1, 3, and XXXI, 4), Foer- 
ster (I.e., p. 217), Hirschberg {Centr. f. Aug., 1891). 

There are several varieties of diabetes mellitus, and the excessive 
amount of sugar in the urine is perhaps the only feature which is 
common to all of them. 

Apart from toxic forms (curare, phloridzin, chloral, sulphuric 
acid, arsenic, alcohol, carbonic oxide, etc.) and the symptomatic mel- 
lituria of injuries to the head and of various cerebral diseases which 
affect the floor of the fourth ventricle, the remaining forms of diabetes 
mellitus appear to be due mainly to disease or abnormal function of 
the pancreas. Sooner or later this gives rise to profound changes of 
nutrition. 

The abnormal increase of sugar in the urine may exist for a long 
time without causing any eye symptoms, and these do not appear in 
the mild forms, including the temporary toxic and traumatic glyco- 
surias. 

In the severe forms, however, the organ of sight is often affected. 
On the one hand, it exhibits symptoms of weakness (of accommoda- 
tion and convergence) , on the other hand, symptoms of auto-intoxica- 
tion by pathological products of disassimilation. The latter include 
diseases of the vessels with their sequelae, fatty degeneration and in- 
flammatory proceses in the tissues themselves. 

The frequent development of cataract is due to disease of the ves- 
sels, particularly in the ciliary processes, and to the consequent dis- 
turbance of the nutrition of the lens. Apart from the causation, this 



CONSTITUTIONAL DISEASES. 435 

cannot be distinguished from cataract due to other causes at the same 
age. As it occurs generally in young people, we have to deal chiefly 
with rapidly progressive, broad-striped, soft cataracts, which are 
often associated at the start with visible swelling of the lens. The 
operation is as satisfactory as in other individuals of the same age 
and nutritive condition. It is only when the nutrition is very much 
impaired that it offers a serious objection to operation. 

A spontaneous clearing up of the opacity of the lens is seen 
occasionally, particularly when the diabetes improves or recovers. 
As a matter of course, iftiis is only possible so long as the cortical 
substance of the lens has not been destroyed. 

The cataract is characteristic only when it appears in both eyes, 
in young people, and without visible cause. Frey {Lond. Med. Rec.^ 
May, 1887) reports double diabetic cataract in a girl of nine years, 
a year after the beginning of the disease. At a later age the devel- 
opment of cataract is much less characteristic. It is to be remem- 
bered that an individual suffering from cataract of old age may be 
attacked by diabetes, and that, on the other hand, an old diabetic 
may suffer from cataract, although in the latter event the diabetes 
is not necessarily the connecting link. 

The development of cataract in diabetes mellitus has been ex- 
plained by various theories. It has been attributed to: 1, the general 
marasmus, although very feeble diabetics are often not attacked by 
cataract ; 2, the removal of fluid from the lens through the medium 
of the sugar dissolved in the tissue juices. In fact, sugar has been 
detected in the lens in two-thirds of the cases, and still more often in 
the aqueous humor and vitreous. The presence of a certain amount 
of sugar for a certain period would, according to this theory, produce 
cataract in all diabetics, and this is controverted by experience. 
Moreover, the opaque as weU as the clear lens may contain sugar in 
diabetes (Leber), and the cataract of one eye may contain sugar 
while the other does not (Becker). 3. Conversion of the sugar in the 
aqueous humor into lactic acid is also said to be the cause. This is 
a pure hypothesis ; the fluid in the aqueous is distinctly alkaline in 
diabetic cataract, and the opacity does not start in the anterior cor- 
tical substance. 



436 THE EYE IN RELATION TO DISEASE. 

We must assume, therefore, that the cataract develops under the 
same conditions as spontaneous cataract, as the result of processes 
in the choroid and particularly in the ciliary processes, which furnish 
the nutritive supply to the lens. The swelling of the lens at the on- 
set and the proliferating processes in its elements warrant the infer- 
ence that irritating substances are present, which stimulate the living 
cells to proliferation and then cause their destruction. 

Changes have been found in a number of cases in the pigment 
epithelium of the uvea, especially of the iris and ciliary processes 
(dropsical swelling, detachment during iridectomy), i.e., in those 
parts which are most important to the nutrition of the lens. The iris 
has also been found more or less changed, partly to a condition of 
simple atrophy, partly to that of slight inflammation. Other uveal 
inflammations may also occur. The development of cataract appears 
to be due, therefore, to toxic substances circulating in the blood and 
not to the harmless sugar ; it is a sj^mptom of auto- intoxication. The 
latter condition includes an entire series of tissue changes in the ves- 
sels, interstitial tissues and parenchyma, which lead to obliteration 
and dilatation of the vessels, oedema and hemorrhage, fatty degener- 
ation and other necrobioses, even to inflammatory affections. This 
condition is analogous to that found in long-continued albuminuria, 
to which the severe forms of diabetes exhibit great similarity (although 
not in regard to the development of cataract) . The similarity of the 
symptoms of severe diabetes to certain chronic poisonings is also evi- 
dent. 

The following diseases of the eye may also occur in diabetes : 

Iritis and irido-cyclitis, the former often associated, according to 
Leber, with hypopyon or fibrinous exudation. The simple forms are 
also frequent, and may vary from the chronic to the acute varieties ; 
they may even be attended by hemorrhages into the chamber. 

Spontaneous short-sightedness, at the age of forty to sixty years, 
without opacity of the lens, must be attributed to swelling or hard- 
ening of the crystalline or to a diffuse affection of the choroid, in 
which the pigment epithelium is affected very slightly or not at all, 
but the sclera is softened and yielding. 

Vitreous opacities, without other visible signs of uveitis, are in 



CONSTITUTIONAL DISEASES. 437 

great part the result of hemorrhages. The latter may be unilateral 
or bilateral (Mackenzie, Ophth. Hosp. Rep., IX, 2, p. 134). 

Relapsing scleritis has been brought into connection with diabetes 
by various writers, but the relationship has not been established pos- 
itively. 

The changes in the retina are inflammatory to a very slight ex- 
tent. The ophthalmoscope shows changes in the vessels and hemor- 
rhages and whitish patches. According to Hirschberg, they are 
always found in diabetes which has lasted more than ten to twelve 
years, and are terminal symptoms of the disease. 

Some of these symptoms are the result of coincident albuminuria 
(owing to epithelial necroses, fatty degeneration and interstitial 
changes in the kidneys), and differ in no respect from retinitis albu- 
minurica. Others are found irrespective of changes in the kidneys. 

Hirschberg (I.e.) distinguishes two principal forms: 1, a variety 
with small, light, shining patches, usually with punctate hemor- 
rhages (retinitis centralis punctata diabetica) . The patches are al- 
ways found in both eyes, the impairment of vision develops gradu- 
ally, and the optic nerve is not affected. Implication of the optic 
nerve, opacity of the adjacent retina and dilatation of the vessels dis- 
tinguish the albuminuric affection from the diabetic form, although 
sometimes the last-mentioned symptoms are present in diabetes and 
absent in albuminuria. 2, a hemorrhagic form, either in the shape 
of small punctate hemorrhages, larger hemorrhages associated occa- 
sionally with vitreous opacities, hemorrhagic infarctions and venous 
thromboses (Michel, Deutsch. Arch. f. kl. Med., XXII, p. 439), or 
even a hemorrhagic glaucoma (Galezowski, Rec. cVOphih., 1873, p. 
90; Knapp, Arch. f. Aug., X, 1, p. 99; Hirschberg, three cases). 
This form is less characteristic than the other. The disturbance of 
sight depends upon the location and size of the hemorrhages. 

Neuritis, neuro-retinitis, choked neuritis, so-called retrobulbar 
neuritis with secondary atrophy of the optic nerve, etc. , are also ob- 
served occasionally in causal connection with diabetes, but the oph- 
thalmoscope shows nothing characteristic. 

On the whole, hemorrhages are the most frequent among diabetic 
diseases of the retina. As in albuminuria, the retinal affections at- 



438 THE EYE IN RELATION TO DISEASE. 

tended with hemorrhages are more unfavorable, as regards progno- 
sis, than those which consist solely of degenerative foci and exuda- 
tions. Similar hemorrhagic lesions are found even more frequently 
within the cranial cavity, where they not alone threaten the organ 
of vision but also life. Hence every diabetic disease of the retina 
has an ominous prognostic significance. 

A hemorrhage behind the retina occasionally leads to its detach- 
ment. 

In long-continued, severe diabetes vascular changes (particularly 
sclerosis) are found not only in the retina, but in almost all the 
tissues of the eye and in many other tissues of the body, especially 
the central nervous system. These also give rise to spontaneous 
hemorrhages into the conjunctiva. 

Various central and peripheral disorders of vision may develop 
during the course of diabetes, such as amblyopia and amaurosis with- 
out findings (almost always bilateral, according to Cohn, and almost 
always unilateral, according to Galezowski), homonymous defects in 
the field of vision (Leber, Z.c, p. 288), homonymous hemianopsia 
(Schiess, Jahres., 1886, p. 50). On the whole, diabetic hemianopsias 
are rare, but they are usually obstinate (Leber, I.e., p. 295). Hemi- 
plegia, aphasia, ataxia, etc., also occur occasionally. Central or 
paracentral scotomata in an almost normal visual field, as in toxic 
amblyopia and probably from a similar cause (auto-intoxication), 
have been reported by Bresgen {Centr. f. Aug., 1881, Feb.), Samuel 
(^6., 1882, July), Lawford {Jahr. f. Aug., 1882, p. 293), Stanford 
Morton (ibid.), Edmunds and Nettleship (ibid.). As the last-men- 
tioned cases occurred in smokers, it is not improbable that the tobacco 
was especially injurious on account of the influence of the diabetic 
auto-infection. [A central scotoma for red has been noted by many 
observers in cases of diabetes. See Leber in Graefe and Saemisch's 
"Handbuch," etc. I have noted it several times. — Ed.] According 
to Hirschberg such cases present a bad prognosis. 

Many of the last-mentioned affections are due to hemorrhages or 
circumscribed spots of softening; otbers are co-ordinate symptoms 
of a lesion situated at the floor of the fourth ventricle. 

Of paralyses of the ocular muscles, which are usually incomplete 



CONSTITUTIONAL DISEASES. 439 

and temporary, paralysis of accommodation is the most frequent. 
Like paralyses in general, this may be one of the first symptoms. 
Pure paralysis of accommodation in middle life is especially sug- 
gestive. Paralyses which develop during advanced stages of diabetes 
are cured with great difficulty. 

Abducens paralysis was observed by Gutmann {Centr. f. Aug., 
1883, Oct.) and Landesberg (Jahr. f. Aug., 1884, p. 323). Kwiatow- 
ski (lb., 1879, p. 224) reports trochlear paralysis; Seegen, double pto- 
sis; Rolland (Arch. f. Aug., 1888, p. 257) and Galezowski (Bee. 
d'Ophth., 1878, p. 3) report paralysis of the motor oculi; Legrange 
and Ogle report facial paralysis. 

These paralyses are due to nuclear and peripheral hemorrhages or 
to peripheral neuritis. The latter lesion is also the cause of the fre- 
quent neuralgias and of the rarer ansBsthesise and sensory disturb- 
ances. Anaesthesia of the first branch of the trigeminus may give 
rise to neuro-paralytic keratitis; neuritis may cause herpes zoster 
ophthalmicus. 

In diabetic coma, which may be associated with cortical visual 
disorders, the odor of acetone is often very strong in the expired air, 
but this sign may also be absent. During the coma the urine is usu- 
ally free from sugar, even if it has been very abundant immediately 
prior to the attack. Hence the cause seems to be an abnormal pro- 
duct of decomposition of the glucose. Diabetes is often combined 
with renal disease, and the latter may produce its characteristic symp- 
toms in the visual organs. 

In advanced diabetes there is a great tendency to the formation 
of furuncles, which may also appear upon the eyelids. Obstinate 
ezcema of the border of the lids is very frequent, and ulcerative pro- 
cesses in the cornea are not uncommon. 

Among 52 diabetics, Lagrange (Arch. d^Ophth., 1887, Jan.) 
found 13 cases of cataract and 13 of hemorrhage into the interior of 
the eye. Among 144 diabetics, Galezowski (Jahr. f. Aug., 1883, p. 
297) observed 5 cases of paresis of accommodation, 4 of parenchyma- 
tous and purulent keratitis, 7 of iritis, 4 of glaucoma, 46 of cataract, 
27 of retinitis, 31 of amblyopia, 10 of paralysis, 4 of hemianopsia, 3 
of detachment of the retiua and 3 of atrophy of the optic nerve. 



440 THE EYE IN RELATION TO DISEASE. 

Among 169 diabetics, Mager {Berl. kl. Woch., 1879, No. 21) found 
only 5 cases of cataract. 

It is evident, therefore, that the urine should be examined for 
sugar in every case of cataract v^hich develops at an unusual period 
and without any known cause, as well as in every case of neuritis, 
retinitis, neuro-retinitis and atrophy of the optic nerve, in every 
doubtful visual disorder, neuralgia or ocular paralysis. Hirschberg 
found diabetes in one per cent of all his private patients. 

Diabetes Insipidus. 

In this condition there is a very notable increase in the excretion 
of urine, without the presence of sugar. It is called polyuria or poly- 
dipsia, according as the increase of the amount of urine or the in- 
creased thirst is regarded as the primary event. 

It is well known that diabetes insipidus is produced by destruc- 
tion of a certain portion of the floor of the fourth ventricle. In 
almost all cases in which visual symptoms and polyuria are associ- 
ated, the latter is a symptom of the same cerebral disease which has 
given rise to the former. For example, van der Hey den {Jahr. /. 
Aug., 1875, p. 191) reports optic neuritis and symptoms of brain 
tumor; Handfield Jones (ibid.) reports pain in the eyes, inequality 
of the pupils, epileptoid attacks; David {ibid., 1889, p. 492) re- 
ports hemianopsia; Raynaud (ibid., 1874, p. 407) reports Raynaud's 
disease with bulimia, polydipsia and visual disorders which occurred 
paroxysmally. Some doubt attaches to Gayet's case {ibid., 1875, p. 
191) of right abducens paralysis with polydipsia and polyuria. 

It is said that opacity of the lens may also develop in pure dia- 
betes insipidus, but this is undoubtedly extremely rare. 

In phosphaturia, Coursserant observed hemianopsia; Dor {ibid., 
1877, p. 208) found phosphaturia seven times among eight cases of 
soft cataract in young people. It would seem, therefore, as if dia- 
betes mellitus, diabetes insipidus and phosphaturia were somewhat 
similar disturbances of nutrition — in the broadest sense of the word 
— and also resembled the excessive production of uric acid (from 
imperfect oxidation, particularly in obese individuals) which not in- 



CONSTITUTIONAL DISEASES. 441 

frequently precedes true diabetes. It is only when the abnormal pro- 
ducts of disassimilation exert a toxic action that the symptoms ap- 
pear which are so frequent in the terminal stage of severe diabetes. 
The excessive excretion of sugar, phosphates, or uric acid in the 
urine is merely the most striking symptom of the disorder of disas- 
similation. The by-products of the latter, for example, ptomaines 
which give rise to necrobioses, necroses and inflammations of the 
tissues, or act as narcotic poisons, are evidently a much greater source 
of danger to the body and the visual organ than the sugar, uric acid, 
or phosphates. 

Basedow^s Disease. 

The main symptoms of Basedow's disease are thyroid enlarge- 
ment, palpitation of the heart, nervous disorders and exophthalmus. 
The latter symptom, like all the others, may be absent or, in rare 
cases, it may be almost the only symptom. It occurs in every possi- 
ble degree, and there may even be paroxysmal or permanent luxation 
of the eyeball in front of the lids. In such cases, suture of the palpe- 
bral fissure is the only means of preventing the loss of the protruded 
eye. As a matter of course, traumatic inflammations of the conjunc- 
tiva and cornea are often present. 

The development of the goitre is usually preceded by increased 
heart's action, but the opposite condition may also obtain. Like all 
the other symptoms of the disease, exophthalmus may occur paroxys- 
mally, may increase or diminish, or maybe permanent and uniform. 

In addition to exophthalmus, there are also other signs of irrita- 
tion of the sympathetic, such as spasm of Mueller's muscle (Graefe's 
symptom). As a result of this spasm, the palpebral fissure is dilated 
and the upper lid lags behind when the patient looks downward. In 
this way the white sclera often becomes visible above the cornea in 
looking downward. Sharkey {Brit. Med. Joiirn., Oct. 25th, 1890) 
found Graefe's symptom absent only twelve times among six hundred 
and thirteen cases. For a long time it may be the sole symptom of 
the disease. 

Moderate dilatation of the pupils with correct reaction to light 
and inequality of the pupils are also observed in many cases, and 



442 THE EYE IN RELATION TO DISEASE. 

are evidences of spasm of the sympathetic. Even the exophthal- 
mus may be due, in part, to spasm of the smooth muscular fibres (pro- 
trusor bulbi) which close the inferior orbital fissure. In great part, 
however, it is the result of oedema, increased congestion and direct 
increase of the orbital tissues. Hence the exophthalmus often di- 
minishes after death. 

A distinct vascular murmur can sometimes be heard in the orbit 
with the stethoscope. It resembles the placental bruit and is proba- 
bly explained in a similar way (Donders, Arch. f. Ophth., XVII, 1, 
p. 102) . Sinuosity and atheroma of the ophthalmic artery have 
sometimes been found post-mortem. 

Unilateral exophthalmus is not very rare (Voelkel, Diss. Berlin, 
1890). Among 20 cases, Emmert {Arch. f. Ophth., XYII, 1, p. 203) 
found 1 unilateral case; among 32 cases, Griffith saw 25 of double, 
4 of right-sided, and 3 of left-sided exophthalmus. This symptom 
often differs in degree on the two sides, being more marked upon the 
side on which the thyroid enlargement is greater. 

Hack (Deutsch. med. Woch., 1885, No. 25) observed disappear- 
ance of the exophthalmus on one side after cauterization of the nasal 
mucous membrane on the same side, and Bobone {Ann. d^Ocul., 96, 
p. 260) claims to have obtained improvement in the same way. A 
few other cases of this kind have been published, but they are very 
exceptional. 

The excessive sweating which is not uncommon in Basedow's 
disease is also a sympathetic symptom. Occasionally there is very 
marked epiphora. 

The tremor may extend to the eyelids (Liebrecht, Mon. f. Aug.y 
1890, Dec.) and may even be confined to the eyes (Freund, Deutsch. 
med. Woch., 1891, No. 8). This symptom and likewise the nystag- 
mus, which is observed occasionally, must be attributed to diminu- 
tion of cortical motor innervation. 

Slight impairment of corneal sensibility is quite common and is 
to be regarded as the cause of the diminution in the frequency of 
winking movements (Stellwag's symptom). In combination with 
the increasing exophthalmus it facilitates the development of trau- 
matic keratitis, which may assume the xerotic or neuro-paralytic 



CONSTITUTIONAL DISEASES. 4:4:3 

form. In some cases the corneal sensibility is ver}^ considerably- 
impaired, but complete anaesthesia is rare. 

In advanced cases the ophthalmoscope often shows pulsation of 
the retinal arteries, occasionally extending far into the periphery of 
the fundus. Becker {Mon. f. Aug., 1880, p. 1) found arterial pulsa- 
tion six times in seven cases. It is probably due to the fact that, as 
a result of the arterial paralysis, the blood pressure falls notably dur- 
ing diastole and becomes so slight, in comparison with the intra- 
ocular pressure, that it causes an entrance of blood into the retinal 
arteries only during the intensified systole of the heart. At the same 
time the intraocular pressure may be normal or even diminished. 
Sinuosity or dilatation of the retinal veins is often noticed. 

Various muscular disturbances have been reported, such as ex- 
'ternal ophthalmoplegia (Schoch and Koeben, Diss. Berlin, 1854;. 
Fischer, Arch, gen., II, p. 521; Stelhvag, Wien. med. Jahi^b., XVII, 
p. 25; Chvostek, Wien. med. Presse, 1872, p. 497; Roth, ibid.,. 
1875, p. 680) and complicated ophthalmoplegia (Warner, Brit. Med. 
Journ., Oct. 28th, 1882; Bristowe, ihid., May 6th, 1886 ; Jendrassik, 
Arch.f. Psych, 1886, p. 301; Ballet, Rec. d'Ophth., VIII., p. 451). 
Implication of the trigeminus, facial, glossopharyngeal, spinal 
accessory and hypoglossal nerves, hemianaesthesias, hemiplegias, 
color blindness, paralyses of the extremities, epilepsy, loss of smell 
and taste, etc., have also been reported. Isolated paralyses of 
the eye muscles (trochlearis, abducens, motor oculi) are rare (Fereol, 
Un. med., 1874, p. 153; Finlayson, Brain, 1890, March). Liebrecht 
(Mon. f. Aug., 1891, p. 182) also mentions paralj^sis of convergence, 
but this was possibly due to notable insufficiency of the interni. 
Complete paralysis of all the external eye muscles and the orbicularis 
has also been reported (Neurol. Centr., 1888, p. 554). The paraly- 
ses appear to be chiefly nuclear, basilar, or root paralj^ses. 

Basedow's disease is often combined with other affections of the 
nervous system, such as syringomyelia, hemichorea, hemiplegia, po- 
lio-encephalitis, multiple sclerosis, bulbar paralysis (the autopsy gave 
negative results) , hysteria, neurasthenia, spinal and cerebral symp- 
toms of all kinds (conjugate paralyses and spasms, central disorders 
of vision) , psychoses, trophic disorders, etc. 



444 THE EYE IN RELATION TO DISEASE. 

Other constitutional anomalies are also observed, such as diabetes 
mellitus and insipidus, Addison's disease (in the face the eyelids are 
chiefly pigmented ; Drummond, Brit. Med. Journ., May 14th, 1887, 
six cases; Mackenzie, Lancet, 1890, II, five cases; even the conjunc- 
tiva may be pigmented, Oppenheim, Muench. med. Woch., 1887, 
No. 52). 

Peripheral visual disorders with ophthalmoscopic findings are rare 
(Story, Ophth. Beview, 1883, p. 161, double optic neuritis; Emmert, 
Arch. f. Ophth., XXVII, 1, p. 203, atrophy of the optic nerve). 
These disorders without ophthalmoscopic findings are quite frequent, 
especially concentric narrowing of the field of vision, with or without 
impairment of central vision or the color sense. Such symptoms are 
commonly bilateral, as in neurasthenia. 

As a matter of course, conditions of exhaustion of the eye (weak- 
ness of accommodation and convergence, asthenopia retinae) are no- 
ticeable. Headache, vertigo, insomnia, impairment of memory and 
the like are probably due to the same cause. Extreme anaemia may 
lead to oedema of the lids and finally to a sort of hemorrhagic diathe- 
sis in which the eye also takes part. The frequent menstrual disor- 
ders (the majority of the patients are females) are to be regarded as 
results, not as causes of the disease. [Diarrhoea is not infrequent. 
—Ed.] 

According to Ballet {Bev. de Med., 1888, Maj^ and July), the 
disease points toward the nuclear region of the facial and ocular mus- 
cles ; he thinks it is located in the medulla oblongata, perhaps as far 
down as the cilio-spinal centre. According to this writer the dis- 
ease is a functional bulbar neurosis; the scanty anatomical changes 
which are found there appear to be secondary. Moebius' theory is 
much more plausible. He believes that we have to deal with the 
toxic effects of products of disassimilation, which are furnished by 
the diseased thyroid gland. These appear to act chiefly on the vaso- 
motor cells and the cortical motor cells. As in all other diseases of 
the kind, we flnd the signs of increasing weakness and diminishing 
nutritive energy, sometimes passing into spontaneous necrosis of 
peripheral parts. It is only in late stages that we find local and dif- 
fuse necrobioses, vessel changes, interstitial inflammations, hemor- 



CONSTITUTIONAL DISEASES. 445 

rhages, multiple neuritis, etc. These occur in chronic toxsemias in 
general, and always exhibit a certain predilection for the region of 
the cerebral muscle nuclei and nerve roots. The principal symptoms 
are toxic phenomena, but these are preceded for a long time by gene- 
ral nutritive disturbances. I desire to call special attention to one 
point. The poisonous action of the noxious substances produced in 
the thyroid gland are noticeable, in the main, in the adjacent cervi- 
cal sympathetic. The oculo-pupillary fibres are chiefly affected ; the 
upper fibres which pass to the vessels of the head are affected to a much 
less extent. This is easily understood in view of the fact that the cur- 
rent in the veins and lymphatics flows toward the heart. The gene- 
ral symptoms are those of a chronic toxaemia, the local toxic symp- 
toms are those of a constant, sometimes a remittent or intermittent 
irritation of the sympathetic at the site of closest proximity to the 
diseased thyroid gland. 

It is also easy to understand that these local symptoms may be 
absent or vary in intensity", if only a certain portion of the gland is 
affected, and that the symptoms are more pronounced, as a rule, on 
the side on which the gland is more involved. 

Hence, the earliest possible enucleation of the larger part of the 
diseased gland is indicated so long as the principal symptoms are 
still local (goitre, palpitation, exophthalmus) . But as the symptoms 
are rarely dangerous at this period, the operation is not performed, 
as a rule, until the chronic general toxaemia is too far advanced. 
Hence, the operative treatment has remained very unsatisfactory de- 
spite a few good results (Rehn, Berl. kl. Woch., 1884, No. 11). [See 
also Mannheim : " Der Morbus Gravesii," Berlin, 1894. Most of the 
authorities advise against operation; see p. 124 et seq. — Ed.] 

Myxoedema. 

In many respects myxoedema (Ord, Lond. Clin. Soc, May 25th, 
1888) is the direct antithesis of Basedow's disease. A characteristic 
feature is the absence of the thyroid gland (cachexia strumipriva) or 
loss of its function. In the latter event the gland may even be enlarged. 

Myxoedema is characterized by a non-oedematous general swelling 
of the skin (no pitting on pressure) , with pallor, coldness and cyan- 



440 THE EYE IN RELATION TO DISEASE. 

osis, resulting in a stupid, dull expression of the face, thickening of 
the lids, lips, tongue, hands and feet. The pulse is slow, the voice 
hoarse and deep ; speech, thought and motion are slow and difficult, 
memory and intelligence are impaired. The patients also suffer from 
mental irritability and depression, pain in the head and back, weak- 
ness of the limbs, loss of the hair and teeth, atrophy or absence of the 
thyroid gland, general anaemia and cachexia and, not infrequently 
at a later stage, from albuminuria. The patients are often cretins 
or idiots, or the affection is the result of extirpation of goitre, 

Ord has demonstrated an increase of mucin, particularly in the 
subcutaneous connective tissue (Horsley found it even in the blood of 
operated monkeys) , so that the disease has been called mucinsemia. 
Yirchow found irritative processes in the subcutaneous tissues. 
"Whether changes in the infundibulum and pineal gland, which are 
not uncommon, are a cause, a symptom, or a result of the disease, 
cannot be decided. 

In addition to implication of the lids in the cutaneous affection, — 
the latter may even begin in this locality {Jahr. f. Aug., 1889, p. 
558 and 561) — amblyopia has been reported in several cases. Wads- 
orth {ib., 1884, p. 390) saw double atrophy of the optic nerve. The 
case of cataract after extirpation of a goitre (Landsberg, ^6., 1888, p. 
308) seems to be very doubtful. 

SoUier {Neurol. Centr., 1892, p. 25) reports two cases of Base- 
dow's disease combined with myxoedema, i.e., with general swelling 
of the skin. The symptoms of Basedow's disease first appeared and, 
after diminution in the size of the thyroid, the symptoms of myxoe- 
dema were superadded. 

It is evident that myxoedema is a profound disturbance of disas- 
similation and nutrition. Its most striking result appears to be the 
increase of mucin, like the increase of sugar in diabetes mellitus. 
The symptoms of auto-intoxication are due, however, to other un- 
known products of abnormal disassimilation. 

Rachitis. 

This is often the cause of so-called laminated cataract, owing to 
a temporary, intense disorder of nutrition in the lens. If it develops 



CONSTITUTIONAL DISEASES. 447 

at a very early period (even intra-uterine) a central cataract forms. 
When this adheres to the capsule of the lens at the anterior and 
posterior poles, it contracts in the course of time into a thread-shaped 
opacity in the axis of the lens, the so-called spindle-shaped cataract. 
Both are merely varieties of laminated cataract. In laminated cata- 
ract proper, the lens substance which has developed prior to the nu- 
tritive disturbance remains transparent, as well as that formed at a 
later period. If the nutritive disturbance returns, a multiple lami- 
nated cataract may develop. 

At the beginning, the laminated cataract appears to be a cortical 
or total cataract. It is only at a later period that the opacity moves 
away from the capsule of the lens on account of the new formation 
of normal cortical substance. The opaque mass of the lens is absorbed 
in part, sometimes with the exception merely of a layer of punctate 
opacities which may be overlooked on superficial examination. 

Laminated cataract is usually present in a similar form in both 
eyes, but it is not infrequently unilateral. It is sometimes congeni- 
tal. Similar forms may also develop after injury to the capsule of 
the lens, which subsequently closes up. The large majority of cases 
develop in the first years of life in rachitic children. 

The violent and long-continued convulsions are the cause of the 
disease, not the rachitis as such. But the real cause is not the gen- 
eral convulsions and the consequent concussion of the body (Arlt), 
but the nutritive disturbance of the lens due to violent spasm of the 
ciliary muscle (associated probably with spasm of the muscular coat 
of the vessels) . I have been able to demonstrate the latter symptom 
with the ophthalmoscope during general convulsions (epilepsy) . It 
is necessary, however, that these spasms occur at a period when the 
growth of the lens is still active, ^.e., before the age of six years. At 
a later period this result follows spasm of the ciliary muscles only 
under special circumstances, when the muscular coat of the vessels 
is affected (ergot in poisoning) , or when the individual is very anae- 
mic (Saemisch) . In the latter event the connecting link is supplied 
not infrequently by a uveal disease (serous iritis) . 

During childhood, rickets is by far the most frequent cause of gen- 
eral convulsions, with the exception of meningitis. The latter ter- 



448 THE EYE IN RELATION TO DISEASE. 

minates much more frequently in death and hence plays no great part 
in the etiology of laminated cataract. 

The opacity does not appear immediately after the convulsions, 
but usually a few days, sometimes even two weeks, later. In rare 
cases it disappears spontaneously. If the cataract is congenital or 
has developed at an early period and is very dense, the symptoms of 
psychical blindness may develop after a subsequent cataract opera- 
tion, as the result of imperfect development of the tracts between the 
brain and eye. 

It is a very interesting fact that an analogous condition is ob- 
srved, under similar circumstances, in another organ which is genet- 
ically co-ordinate with the lens, viz., the enamel of the permanent 
teeth (Horner). The teeth, particularly the upper incisors, often ex- 
hibit horizontal grooves and ridges (Fig. 21), i.e., places in which 
the enamel is alternately present and absent. This produces 
• ^^ a characteristic appearance which is entirely different from 
that of hereditary syphilis. The change is only seen dis- 
tinctly during the first few years after the appearance of the 
teeth. The latter soon crumble at the parts which are destitute of 
enamel, so that later only stumps of teeth remain. 

It is not surprising that laminated cataract may be present with- 
out rachitic teeth, and vice versa, because both conditions are the re- 
sults of local spasms in the ciliary body and the vessels of the enamel 
respectively. These local spasms may be entirely absent, or they are 
not always present at the same time in both organs. When present, 
they warrant a probable diagnosis of rachitis in infancy, unless some 
other cause can be demonstrated. 

In osteomalacia no special eye symptoms have been reported, 
apart from evidences of weakness. 

In conclusion, we will discuss a few constitutional anomalies 
which are closely related to the chronic infectious diseases. 

Leukcemia. 

Like the chronic infectious diseases, leuksemia also possesses a 
specific new-formation. This consists of lymphoid tissue like that, 
found in the spleen, lymphatic glands and medulla of the bones. 



* CONSTITUTIONAL DISEASES. 449 

At the onset of the disease the symptoms of progressive weakness 
predominate, as in every notable disturbance of nutrition. At a later 
period the signs of auto-intoxication make their appearance. Hence 
leukaemia should really be considered among the diseases of the cir- 
culatory apparatus, if we were certain that the changes in the spleen, 
medulla of the bones and lymphatic glands were primary. They may 
be due, however, to some noxious agent which is already in the or- 
ganism, especially as true leukaemia is often preceded for a long 
time by disorders of digestion and nutrition. 

The disease usually runs a A^ery chronic course, and there may be 
no eye symptoms, apart from the general symptoms of weakness; 
this often lasts until death. On the other hand, eye symptoms may 
lead to the recognition of the disease. 

In a series of cases, retinitis occurs (almost always bilateral) as in 
albuminuria. There are two principal varieties, one accompanied 
by hemorrhages, the other by whitish patches ; the former is more 
frequent. The hemorrhages often exhibit a white centre (symptoms 
of absorption) , but this is not pathognomonic, as Poncet believed. 
The retina itself may be normal or more or less cloudy, occasioually 
milky and strewn with hemorrhages (Perrin, Gaz. des Hop., 1870, 
p. 191). According to Roth's findings {Virch. Arch., 49, p. 441), 
this opacity appears to be due to finely granular cloudiness of the 
nerve-fibre layer. 

Post-mortem examination shows that the vessels are, in the main, 
unchanged (Poncet, Gaz. des Hop., 1874, p. 360; Gallasch, Jahr. 
f. Kind. , VI, 1) ; hemorrhages, oedema and cellular infiltrations are 
found in the papilla, retina and choroid. The latter may be so ex- 
tensive as to form neoplasms which are even visible with the ophthal- 
moscope (Becker). Oeller found the choroid thickened sixfold by 
cellular infiltration. In addition, the retina exhibits hypertrophy of 
the radial fibres and sclerotic nerve fibres. The peripheral oedema 
of the retina, which is occasionally mentioned, has no significance; 
it occurs normally at a certain age. 

In other cases, however, vessel changes have been demonstrated : 

dilatation and sinuosity, thickening and round-cell infiltration of the 

adventitia in spots, visible occasional^ with the ophthalmoscope 
29 



450 THE EYE IN RELATION TO DISEASE. 

as a whitish sheath around the vessels (Tillaux, Rec. d^OpMh., 1878, 
p. 461) ; also advanced fatty degeneration of the walls of the vessels, 
especially of the peripheral branches (Roth) , and sclerosis of the ves- 
sel walls (Kramsztyk, Jahr. f. Aug., 1878, p. 226). Venous throm- 
boses also occur (Michel, Deutsch. Arch. /. kl. Med., XXII, p. 439). 
The choroid may be unaffected, or it may also exhibit hemorrhages, 
infiltrations and vessel changes. 

Other lesions which have been observed are vitreous hemorrhages, 
occasionally very prof use (Saemisch, Mon. f. Aug., 1869, p. 305), 
simple and retrobulbar neuritis (usually hemorrhage into the optic 
nerve) , occasionally an enlargement of the papilla like choked disc 
(Oeller) , or a fungus-shaped enlargement due to cellular infiltration 
(Poncet) . 

Hemorrhages into the conjunctiva and face (eyelids) belong to the 
terminal stage and are not very frequent. In acute cases they may 
be the first symptom which calls attention to the disease. 

In severe forms of leukaemia, a light or orange yellow color of the 
fundus may be visible, but this is very rare. Liebreich ("Atlas"), 
Litten (Jahr. f. Aug., 1889, p. 491), Becker {Arch. f. Aug. u. Ohr., 
I, 1, p. 94), Kramsztyk {I.e.) report cases of this kind. I have seen 
this condition in a single case. Quincke {Jahr. f. Aug., 1880, p. 
236) mentions a very pale red fundus. It is usually stated that the 
color of the fundus presents no striking change even in advanced 
leukaemia. The contents of the vessels may or may not be very pale. 

Leukaemic neoplasms occur in the lids and orbit, and also within 
the eye and brain. Friedlaender {Virch. Arch., 1878, 2, p. 362) re- 
ports nodular lymphomata in the medullary substance and cortex of 
the brain (and the internal granular layer of the retina) , with ampullae 
of the optic nerve {vide p. 143) . These produce the clinical symptoms 
of brain tumor. Leber {Arch. f. Ophth., XXIY, 1, p. 295) observed 
double hemorrhagic retinitis, symmetrical swelling of all the eyelids 
and double exophthalmus, from leukaemic proliferations in the orbits. 
Guaita {Jahr. f. Aug., 1890, p. 239) reports thickening of all the 
lids in pseudo-leukaemia. Osterwald {ih., 1881, p. 454) observed leu- 
kaemic tumors in the orbit. Birk {ih., 188, p. 298) found the poste- 
rior part of both orbits filled with a "lymphatic" new-formation. 



CONSTITUTIONAL DISEASES. 451 

May (lb., 1884, p. 351) describes a circumscribed leukaemic infiltration 
of the facial nerve in the Fallopian canal; Becker (I.e.) a leuksemic 
tumor of the retina. Perhaps Oeller's case should be regarded as a 
leuksemic tumor of the choroid, but it may also have been an exten- 
sive hemorrhage. Gallasch found the lachrymal glands converted 
by enormous lymphoid infiltration into tumors as large as a pigeon's 
egg. Delens {JaJir. f. Aug.^ 1886, p. 475) reports the cure of leukse- 
mic tumors of the orbit as the result of cholera. 

Under the term iritis leuksemica, Michel (Arch. f. Ophth., XXYIl, 
2, p. 25) describes a case of bilateral chronic iritis with occlusion of 
the pupils in a woman of thirty-six j^ears, who also suffered from 
slight enlargement of the spleen and lymphatic glands and tempo- 
rarj- increase in the number of white blood globules. The excised 
iris contained nodules of lymphoid and epitheloidal cells, which were 
partly calcified ; these were not visible to the naked eye. It is doubt- 
ful, however, whether this case should be regarded as leukasmia. 

The enormous increase in the number of white blood globules is 
the most striking and characteristic symptom of leukaemia, but it 
does not constitute the source of danger to life. This is due to path- 
ological products of disassimilation, which may not only exert a "for- 
mative" irritation in various parts (leuksemic tumors), but may also 
have a direct toxic action. This is either acute and resembles scurvy, 
or it is less violent and consists of the production of necrobiotic and 
inflammatory processes in the vessels and tissues. 

To a certain extent the cells of leuksemic tumors may be regarded 
as infected and infecting tumor cells. They thus constitute a tran- 
sition to malignant tumors (malignant multiple tumors of the lym- 
phatic glands are actually called pseudo-leuksemia) whose clinical 
symptoms, in the later stages, are very similar to those of leukaemia. 

Tumor Cachexia. 

This may be regarded as an infectious disease whose micro-organ- 
ism is the malignant specific tumor cell (sarcoma, cancer) . It is pos- 
sible that the tumor cell itself is infected by a bacterium and thus 
becomes malignant. The tumor cell is the element of the specific 
neoplasm, as opposed to the "granulation tumors" (syphiloma, 



452 THE EYE IN RELATION TO DISEASE. 

leproma, tubercle, etc.), which develop solely from the action of the 
specific bacterium upon the infected tissues. 

Malignant tumors may long remain local and give rise to merely 
local destructions. Even then, secondary infection from without 
may give rise not only to local inflammation and suppuration, but 
also to general infection, to septicaemia and pysemia. 

It is also evident that malignant tumors produce substances which 
are chemically irritating and productive of inflammation. At the 
periphery of the neoplasm these substances cause emigration of cells 
and proliferation in the adjacent tissues (zone of reactive inflamma- 
tion) ; on the other hand, they exercise a disturbing effect on the gen- 
eral nutrition, may even have a direct toxic action, and thus give 
rise to the so-called tumor-cachexia. In such cachectic conditions 
hemorrhages may develop in all the organs, including the eye, — for 
example, retinal hemorrhages (Mackenzie, Jahr. f. Aug., 1883, p. 
298, in cancer of the stomach) . 

It is also possible that purely toxic actions may produce condi- 
tions similar to those in other chronic and subacute poisonings, viz., 
renal diseases and their sequelse, fatty degenerations and hemor- 
rhages, especially in the retina and brain, multiple neuritis, 
peripheral and nuclear paralyses of the ocular muscles, etc. The 
partial paralysis of the left motor oculi nerve in cancer of the 
pylorus, which was observed by Bettelheim {Jahr. f. Aug., 1888, p. 
571), probably belongs to this category, although such purely toxic 
effects are rare. The chief symptoms are due to " specific neoplasms, " 
to emigrating and proliferating tumor cells in the lymphatic and 
blood channels. 

As a matter of course, the tumor may also originate in and about 
the eye (retinal glioma, choroidal sarcoma, cancroid of the conjunc- 
tiva and lids, sarcoma of the conjunctiva, etc.) and then give rise to 
metastases which may, in turn, produce ocular symptoms, — for ex- 
ample, when the metastases are situated in the nervous system. 
Metastases in one eye are rarely secondary to a growth in the other 
eye (choroidal sarcoma) ; a more frequent event is the spread from 
one eye to the other (glioma of the optic nerve and retina) or the co- 
incident affection of both eyes (sarcoma of the choroid and glioma 



CONSTITUTIONAL DISEASES. 453 

of the retina) . Tumors in other parts of the body rarely produce me- 
tastases in the eyes, but a number of cases have been reported, three- 
quarters of which started from tumors of the breast. The eye is sec- 
ondarily affected in a much larger number of cases by metastases in 
the orbits, but particularly within the skull, where they may give 
rise to all the symptoms of a primary tumor. 

In the eye itself, the choroid is almost always the structure which 
is affected by metastasis, but Elsching {A7^ch. f. Aug., XXII, 2 and 
3) has also described a metastatic tumor of the optic nerve. 

The eye possesses diagnostic importance not alone in the living 
but also in the dead, inasmuch as it presents certain important, al- 
though not infallible, signs of death. 

The so-called sclerotic patch, a desiccated portion of the sclera to 
the inner or outer side, or below the cornea, in the palpebral fissure, 
opacity and insensibility of the cornea, abolition of the pupillary re- 
action to light, xerosis of the cornea and conjunctiva, usually develop 
shortly after death. They are also observed occasionally during life 
(cholera, cholera infantum, etc.). 

According to Poncet {Arch. gen. de Med., 1870, p. 498), conver- 
sion of the red color of the fundus into yellowish-white, complete dis- 
appearance of the retinal arteries and narrowing of the veins, are 
positive and suddenly developing signs of death. As a matter of 
course, this is really only a sign of the cessation of the circulation of 
the blood in the retina and choroid. Nevertheless, this change in 
the color of the fundus is one of the most positive early signs of death. 

To make a brief resume of the previous considerations, we find 
that in the secondary ocular affections of the most varied diseases — 
apart from those which have a direct or indirect mechanical action 
upon some part of the body which is optically efficient — there is a cer- 
tain uniformity which points to a similar mode of development. 
We have to deal, in fact, with toxic symptoms in the broadest sense 
of the term, from the most acute to the most chronic, as we have de- 
scribed on p. 360. 

The differences are due mainlv to the fact that in one case the 



454 THE EYE IN RELATION TO DISEASE. 

virus is introduced into the body, in another it is produced in the 
body, either with or without the aid of living elements. 

Improper articles of diet give rise to changes in the stomach and 
intestine, an unsuitable composition of the atmosphere entails changes 
in the respiratory organ, and, secondarily, changed chemical condi- 
tions of nutrition in the entire organism. If the latter are sufficient- 
ly intense and prolonged, true organic disease will be produced, 
very often combined with vessel changes and their sequelae. This 
takes place particularly in the small arteries and capillaries, where 
the noxious substances which have been absorbed in other parts 
pass the walls of the vessels. These substances act first upon the 
walls of the vessels and the interstitial connective tissue, and they 
affect the parenchyma (cells, nerve and muscular fibres) only when 
they have been very abundant from the start. 

In these auto-intoxications we also find that a certain virus attacks 
certain organs more than others. These organs are either the site 
of the greatest accumulation of the virus, or their constituents are 
especially sensitive to the virus, evidently on account of the pres- 
ence or absence of certain chemical substances. The predominant 
affection of certain organs then impresses a peculiar character upon 
the entire clinical history. In this regard, a spontaneous contracted 
kidney or cirrhotic liver exactly resembles diabetes or Basedow's 
disease. 

The clinical history is often complicated by secondary infections 
with living inflammation-producers of all kinds, and it is a general 
rule that an infection during an already existing constitutional 
anomaly is more serious and obstinate than infection in a healthy 
individual. 

In infections, the purely toxic action is supplemented by that of the 
infectious emboli and thrombi. After destruction or elimination of 
the germs, the purely toxic " constitutional anomaly" remains. This 
either returns to the normal condition — complete recovery — after more 
or less prolonged convalescence, or a permanent condition of ill health 
remains which exhibits a different character, according to the quan- 
tity and quality of the tissue changes and destructions. There may 
then be a tendency to definite diseases of certain tissues and organs. 



CONSTITUTIONAL DISEASES. 455 

which are often characteristic of the previous disease. In such cases 
the changes in the visual organ often possess the highest diagnostic 
importance. 

It is well known that the organized producers of inflammation 
themselves rarely constitute the dangerous element, but that this con- 
sists, as a rule, of certain of their metabolic products, ^.e., of chem- 
ical substances. In like manner, the proliferation and destruction of 
the bacteria depend upon the presence of certain chemical substances 
which are present or are produced in the infected body. The prolif- 
eration of the microbes is not only counteracted by a certain degree 
of concentration of their own metabolic products, but also by certain 
chemical elements and metabolic products of the diseased body. 
Hence, infection with a certain microbe may fail (immunity) at one 
time, produce a mild affection at another time, and a severe disease 
a third time. The same micro-organism may produce very different 
processes in different individuals, and, on the other hand, different 
organisms may produce very similar affections in different individ- 
uals. This may often be very clearly demonstrated during implica- 
tion of the visual organ in the morbid process. 

Hitherto the study of the diseases in question has been mainly 
morphological. Our knowledge of the chemical changes is still very 
imperfect, and usually refers merely to certain striking substances 
(sugar, albumin in the urine, etc.) which, with few exceptions (te- 
tanotoxin in traumatic tetanus, and a few others), are not the real 
toxic agents. The chemical metabolic products of the microbes and 
other chemical constituents of the infected body are, however, at least 
as important as the specific micro-organism in the production of a 
definite clinical complex, and sometimes even more important. 

Here a large field, which has hardly been touched, is opened to 
physiological and pathological chemistry. 



INDEX. 



Abducens, nuclens and course of, 23 
Abscess of brain, 136 

course and symptoms of, 136 
Acne rosacea, 255 

connection with chalazion of, 255 

treatment of, 256 
Acne vulgaris, 254 

connection between hordeolum 
and, 255 
Acromegaly, 201 
Aconitine, 326 
Addison's disease, 433 
^sculin, 326 
Agraphia, 102 
Agoraphobia, 237 
Alexia, 101 
Alcohol, 326 

acute poisoning, symptoms of, 326 

amblyopia, 328 

chronic poisoning, ocular effects, 
327, 331 

ophthalmoscopic examination, 327, 
328 

optic neuritis, 327, 328, 329 
Amaurosis, hysterical, 33 
Amblyopia, hysterical, 33 
Amyl alcohol, 331 
Amyl nitrite, 331 

Anatomical course of nerves of eye, 2 
Aneurisms, 297, 298 
Anthrax, 371 
Anaemia, 288-290, 429 

arcus senilis, 429 

atrophy of optic nerves, 430 

catarih of conjunctiva, 429 

hemorrhages, 429, 430 

icterus of conjunctiva, 429 

marantic keratitis, 430 

neuritis, 430 



Anaemia, ophthalmoscope in, 289, 290 

oedema of lids, 429 
Anisocoria, 114 
Antipyrin, 332 
Antifebrin, 332 
Anilin, 332 
Aphasia, 99 

optic, 99, 101 
Apomorphine, 332 
Arsenic, 333 
Argentum nitricum, 332 
Ascending paralysis, acute eye symp- 
toms, 197 
Ataxia, hereditary, 195 
Atrophy and degeneration of fibres and 
cells in the newly born, 15 

after destruction of occipital cor- 
tex, 14 

after division or degeneration of 
optic nerve, 11 
Athetosis, 241 
Atropine, 333 

Basedo^v's disease, 441 

exophthalmus, origin of, 441, 444, 
445 

exophthalmus, unilateral, 442 

Graefe's symptom, 441 

orbital murmur, 442 

paralysis of eye muscles, 443 

retinal arteries, 443 
Belladonna, 334 
Beri-beri, 399 

glaucoma, 399 

optic nerve, atrophy of, 399 
Blennorrhoea neonatorum, 322 
Blood-vessels and the eye, relations 
between, 123 

arteries, 123 



458 



INDEX. 



Blood-vessels — brain, vascular supply 
of important parts of, 124 
veins, 126 • 
Blood-vessels, extensive disease of, 293, 
294 
hemorrhages into eye in, 293, 294 
Botylismus, 334 
Brain, abscess of, 136 
diseases of, 130 
symmetrical occurrence of diseases 

of, 62 
tumors of, 138 
Brain, cord, and nerves, individual 

diseases of, 130 
Brain, frontal, 104 
functions of, 104 
diseases of, 106 
Brain and membranes, anaemia of, 130 
hypersemia of, 130 
retinal examination in anaemia and 

hyperaemia, 130 
symptoms of anaemia and hyper- 
aemia, 131 
Bulbar paralysis and allied diseases, 176 
Burns, extensive, 370 

retinal hemorrhages in, 370 

Caffeine, 335 

Calabar, 335 

Calomel, 335 

Cannabis indica, 335 

Carbolic acid, 335 

Carbonic oxide, 335, 336, 337 

Carbon sulphide, 354 

Cataract during chronic cutaneous 

eruptions, 261 
Cavities adjacent to nose, diseases of, 
279 

ocular effect, due to, 279, 280 
Cerebral cortex, elements of, 10 
Cerebral ganglia, primary, diagnosis 

of lesions of, 55 
Cerebral tumors, 138 
Chalazion, 255 

treatment, 256 
Cheyne-Stokes breathing, 171 

pupillary symptoms with, 171 
Chiasm, course of fibres in, 4-6 
Chiasm, disorders of, 38 

complete destruction, 38 

partial destruction, 38 



Chiasm, disorders of — hemianopsia due 
to partial destruction, 38 

hemianopsia, occurrence of, 38 
Chloral, 337 
Chloroform, 337, 338 

effect on pupils, 337, 338 
Chlorosis, 432 

catarrh of conjunctiva, 433 

oedema of lids, 433 

pulsation of retinal arteries, 433 

retina, 433 
Choked disc due to cerebral tumors, 
140 

pathology of, 144 
Cholera, 386 

choroidal hemorrhages, 387 

cornea, changes in, 387 

cyanosis, 387 

hemorrhage into conjunctiva, 387 

pupils in, 388 

retinal arteries, 387, 388 
Cholera infantum, xerotic keratitis 

due to, 270 
Chorea, 240 

emboli as cause of, 240, 241 

occurrence, 240 

ophthalmoscopic examination, 241 
Chromic acid, 338 
Chrysarobin, 338 

Circulatory organs, diseases of, 288 
Cirrhosis of liver, ocular affections due 

to, 272 
Cocaine, 339 
Coffee, 339 
Coitus, a cause of retinal hemorrhages, 

312 
Commissure of Gudden, 5, 6, 7, 12 
Coniine, 339 

Constitutional diseases, 428 
Cornea, 

peripheral anaesthesia of, in dis- 
orders of sensory nerves, 107 

hysterical anaesthesia of, in dis- 
orders of sensory nerves, 108 
Corona radiata, central disorders of 

vision from lesions in, 67 
Corpora quadrigemina, 

function of, 44, 47 

lesion of, 43 
Corpulence, 430 
Cortex, frontal, surface disease of, 107 



INDEX. 



459 



Cortex, visual, hallucinations due to 

the irritation of, 65 
Cortical disorders of vision, 57 
Creosote, 339 
Curare, 339 
Cytisin, 340 

Daturine, 340 

Day blindness, 36 

Death, signs of, in the eye, 453 

Diabetes insipidus, 440 

opacity of lens in, 440 
Diabetes niellitus, 434 

amaurosis, 438, 439 

amblyopia, 438, 439 

cataract, 435, 436. 439 

furuncles upon eyelids, 439 

hemianopsia, 438 

hemorrhages, 437, 438 

irido-cyclitis, 436 

iritis, 436, 439 

neuritis, 437, 439 

paralysis, 438, 439 

retinal changes, 437, 439 

scleritis, 437 

uvea, as affected b}-, 436 

Diagnosis of affections of the eye, 128 
Diarrhoea, ocular effects due to, 269 
Differential stimulus, 36 
Digestive organs, diseases of, 265 
Digitalis, 340 
Diphtheria, 389 

paralysis, 389, 391 

visual disturbances following, 391 
Duboisine, 340 
Dysentery, 389 
Dyslexia, 102 

Ear, diseases of, 280 

blepharospasm in, 280 

cataract in, 283 

Meniere's disease, 282, 283 

narrowing of field of vision, 281 

nystagmus, 281 

optic vertigo in, 280 

suppuration of middle ear, 281, 282 

vision as affected by, 281, 282 
Eczema, 250 

catarrh of conjunctiva in, 250 

of conjunctiva and cornea, 250, 252 



Eczema of eyelids, 250, 253 

origin of, 251 

phlyctenulse, 252 
Elements of the cerebral cortex, 10 
Elephantiasis Arabum of eyelids, 249, 

260 
Embolism in the eye, 296, 297 
Embolism, cerebral, 135 

complications, 135 

course and symptoms, 135 
Encephalitis, diffuse, 170 
Endocarditis, ulcerative, 371 
Epilepsy, 233 

agoraphobia, 237 

congenital anomalies of eye in, 236 

cortical, 237 

Graefe's sj^mptom, 236 

hemorrhages, 234 

nystagmus, 235 

operations as cause of, 236 

ophthalmoscopic examination, 233, 
234 

pupils in, 235. 236 

spasm of ocular muscles in, 235 

Stellwag's symptom, 236 

unilateral, 236, 237 

visual aura, 234, 235 

vision, narrowing of field in, 236 
Ergotin, 240 
Erysipelas, 248 

abscesses, 248 

dacryocystitis, acute, 248, 249 

embolism of cerebral artery, 249 

of eyelids, 248 

keratitis, bullous, 248 

thrombosis of retinal vessels, 249 
Erythrophl83in, 341 
Eserine, 341 
Ether, 341 
Ethyl chloride, 341 
Ethyl diamin, 342 
Ethyl dichloride, 342 
Ethyl nitrite, 342 

Exposure to cold as a cause of eye dis- 
ease, 263 

Facial nerve, 

diseases of, 211 

nucleus and course of, 23 
Fibroma molluscum of eyelids, 260 
Filix mas. 342 



460 



INDEX. 



Fish and meat poisoning, 342 
Frontal brain, 104 

diseases of, 106 

functions of, 104 
Functional neuropsychosis, 211 
Fundus oculi, disturbances of color 

sense in diseases of, 28 
Fungus, 342 
Fusel oil, 343 

Ganglion habenulse, 50, 54, 56 
Gastric catarrh, chronic, 266 

optic nerve, as affected by, 266 
Gelseraium, 343 
Geniculate body, external, 45, 53. 54, 56 

ophthalmoscope in diseases of, 56 
Gerlier's disease, 399 
Glanders, 370 
Gonorrhoea, 312 

metastatic iritis, 312, 313 

source of infection, 312 
Gratiolefs optic radiations, 8, 9 
Guddens, commissure of, 5, 6, 7, 12 

Haab's cortical reflex of the pupil, 110 
Haemophilia, 433 
Hasheesh, 343 
Hemeralopia, 34 

with hepatic affections, 271 
Hemiachromatropsia, 62, 63 
Hemianopic pupillary reaction, 40, 55, 

56 
Hemianopic light rigidity, 40 
Hemianopsia, visual disorders in, 58 

bilateral, 61 

color, 62 

cortical, 58 

homonymous, 40 

in lesions of chiasm, 38 

in lesions of entire occipital cortex, 
58 
Hemorrhages, cerebral, 131 

choked disc, 134 

development, 131 

hemianopsia in, 131 

mydriasis in, 133 

ophthalmoscopic examination in, 
134 

optic nerve, atrophy of, 134 

pupils in, 132, 133 

remote symptoms, 132 



Hemorrhages, general, 270, 290-292 
Hemorrhages, hemorrhoidal, 270 
Hepatic affections with xantlielasma, 

273 
Herpes vulgaris, 253 

of cornea, 253, 254 
Herpes zoster, 253 
Hippus, 116 
Homatropine, 343 
Horse chestnut, ^43 
Hydracetin, 343 
Hydrocephalus, chronic, 157 
Hyosciue, 343 
Hypnosis, 

blindness in, 227 

color blindness in, 228 

eye in, 226 
Hypochrondria, 233 

and neurasthenia in diseases of 
sexual organs, 313 
Hysteria, 212-223 

anatomical changes, 218-221 

cortical nature of, 223 

disorders of muscles, 214-216 
of secretion, 217 
of sensation, 216, 217 
of sight, 212-214 

optic nerve in, 217, 218 

predisposition to, 221 

Ichthyosis of eyelids, 260 
Illuminating gas, 343 
Infectious diseases, 360 

affections of eye in, 362-365, 366, 

367 
eye as point of entrance for infec- 
tion, 362 
functional results of affections of 

eye in, 367, 368 
infectious embolism and tlirom- 

bosis, 365 
micro-organisms in, 360, 361, 362 
Influenza, 392 

atrophy of optic nerve, 395 
blepharospasm, 396 
conjunctiva, affections of, in, 392 
embolism of central artery, 394 
glaucoma, 394 
herpes, 393 

inflammation of Tenon's capsule, 
394 



INDEX. 



461 



Influenza, iritis, 394 

neuralgias of eye, 393 

paralyses, 395 

visual disorders, 395 
Initial stimulus, 36 
Injuries to brain, 171 

atrophy of optic papilla, 172 
Innervation of muscles of eye, 16 
Insanity, 159 

congenital anomalies of eye in, 160 

diseases of eye as cause of, 160 

hallucinations, 162 

operations upon eye as cause of, 160 

ophthalmoscope in, 159 
Interior of eye and cornea, nerve fibres, 

26 
Intermediate visual disorders, 43 
Intestinal worms, 268 
Intra-ocular visual disorders, 28 
Investigations on the course of fibres 

in brain, 9 
Iodine and iodide of potassium, 343 
Iodoform, 344 

Involuntary muscles of the eye and of 
the sympathetic, disorders of, 109 

Jaundice, yellow conjunctiva in, 271 

yellow vision in, 271 
Jaundice with xerosis of conjunctiva, 
271 

Keratitis, neuro-paralytic, 107, 119 

Lachrymal secretion, disturbances of, 

122 
Lactation, 321 
Lead, 345 
Leprosy, 425 

anaesthesia of cornea, 426 

eyebrows and lids invaded by, 426 
. irido-choroiditis, 427 

iritis, 427 
Leptomeningitis, chronic, visual dis- 
turbances in, 157 
Leukaemia, 448 

hemorrhages, 449, 450 

iritis, 451 

neoplasms, 451, 500 

retina in, 449 
Lupus, 247 
Luys' bodies, relation of optic tract to, 8 



Lymphatics and the eye, relations be- 
tween, 127 
Lyssa, dilatation of pupils in, 371 

Malaria, 401-404 

amblyopia, 401, 403 

blindness, 401, 402 

congestion of retina and optic 
nerve, 402 

conjunctiva, 401 

dilatation of pupils, 401 

hemianopsia, 403 

herpes, 404 

iritis, 402 

keratitis, 403 

muscular spasms and paralyses, 401 

neuralgias, 401 

neuritis, 402 

night blindness, 404 

pigmentary deposits, 402, 403 

retinal hemorrhages, 402 

vitreous opacities, 402 
Malignant oedema, 371 
Malignant pustule, 371 
Marsh gas, 346 
Masturbation, 311, 312 
Measles, 374 

affections of eye in prodromal 
stage, 374 

dacryo-adenitis, 376 

keratomalacia, 375 

optic neuritis, 375 
Memory centre for visual impressions, 

101 
Meningitis, 150 

keratitis, desiccation, 156 

optic neuritis, 151, 152 

papilla, changes of, 152 

trigeminal affections, 151 

visual disorders, 152 
Meningitis, epidemic cerebro-spinal, 
156 

cataract in, 157 

conjunctival catarrh, 156 

corneal infiltrations, 156 
Meningitis, purulent, 153-156 

choroiditis, 153, 155 

extension of inflammation into 
orbit, 153 

occurrence and prognosis, 154 

panophthalmitis, 155 



462 



INDEX. 



Meningitis, tubercular, 151, 156 
Menstruation, 313 

amenorrboea, 316 

anomalies of, in tbe bealthy, 315, 
316 

congestion of fundus oculi, 314, 315 

dysmenorrboea, 316 

eruption on lids and cornea, B14 

exacerbations of existing diseases, 
814 

hemorrbages preceding and dur- 
ing, 313, 315, 317, 319, 320 

sudden suppression, 317 
Menthol, 346 
Mercury, 346 
Metastases in general septic infection, 

320, 321 
Metbyl alcohol, 347 
Methyl chloride, 347 
Meynert's commissure, 5, 6, 7, 12 
Migraine and scintillating scotoma, 237 

epilepsy, 237, 238 

paralytic form, 238 

spastic or tonic form, 238 
Morphine, 347 
Morvan's disease, 201 
Motor cortical centres and relation to 

ocular movements, 74 
Motor nerves, 

constituents of nucleus of, 74 

course of, 16 
Motor oculi, 

course of, 16 

nucleus of, 17 
Motor sympathetic, origin and course 

of, 24 
Multiple neuritis, 204 

causes of, 204 

inflammation of anterior and pos- 
terior roots of spinal nerves, 204, 
205 
Multiple sclerosis, 179 

mobility of eye, 180 

nystagmus, 179 

ophthalmoscopic examination, 182 

pathology, 182 

pupils, 180 

visual disturbances, 181 
Mumps, 398 

chemosis of conjunctiva, 398 

conjunctivitis, 298 



Mumps — epiphora, 398 

irido-cyclitis, 898 

lachrymal glands. 398 

oedema of lids, 398 

optic neuritis, 398 

paralysis, 398 
Muscarine, 348 
Mussel poison, 848 

Mydriasis in cerebral hemorrhage, 111 
Myelitis, acute, 197 
Myelitis, transverse, eye symptoms, 198 
Myosis, 118 
Myxoedema, 445 

Naphthalin, 348 

Nerves, diseases of, 204 

Nerves of the eye, anatomical course 

of, 2 
Nervous system, diseases of, 1 
Neurasthenia, 231 
Neuropsychosis, functional, 211 
Newly born, injuries to eyes of, 321 
Nicotine, 348 
Night blindness, 84 
Nitro-benzol, 348 
Nitrous oxide, 348 
Nose, diseases of, 274 

asthenopia in, 279 

blepharospasm, 279 

eczema of nasal mucous membrane, 
276 

lachrymal duct as channel for dis- 
eases, 274 

mydriasis, 279 

occlusion of lachrymal duct, 275 

ocular reflexes, 278 

operations, visual disorders after, 
278 

rhinoscleroma, 277 

scotoma, scintillating, 279 

suppuration in nose as cause , of 
iritis, 277 
Nothnagel's perceptive centre, 59, 100 
Nystagmus, 81 

cause, 83 

forms, 82 

occurrence, 83 

Obesity, 430 

Occipital cortex, results of lesions of, 

58, 59 



INDEX. 



463 



Ocular muscles, congenital absence of, 

73 
Ocular muscles, congenital paralyses 

of, 73 
Ocular muscles, nuclear paralyses of, 
71 
course, 72 
diagnosis, 71 
pathology, 73 
Ocular muscles, voluntary, disorders 
of, 69, 70, 73 
cortical spasms, 84 
peripheral paralyses, 69 
Ocular nerves, disorders in domain of, 

27 
Ophthalmoscope in peripheral visual 

disorders, 41 
Opium, 349 
Optic ganglia, primarj-, 43 

degeneration of fibres of, 46 
functions of, 46 
lesions of, 43 
Optic nerve, 

after partial destruction or slow 

degeneration of, 37 
anatomical course and distribu- 
tion, 2-6 
atrophy after division or degenera- 
tion, 11 
atrophy in cerebral hemorrhage, 

134 
color disturbance in disease of, 37 
conduction of stimuli in, 13 
diseases of, 36 
disorders of, 27, 28 
hereditary affections of, 158 
kinds of fibres in, 12 
macular fibres of, 4 
number of fibres in, 13 
ophthalmoscopic examination, 38 
Optic thalamus, 45, 51, 52, 53 

disorders of, 40 
Optic tract, 

relation of, to Luys' bodies, 8 
scotomata due to interference v\'ith 

conduction in, 41 
termination of fibres of, 6-8 
Oxalic acid, 349 

Pachymeningitis, hemorrhagic, 158 
Paragraphia, 103 



Paralysis agitans, 170 

Paralyses, i)eripheral, of ocular mu- 
scles, 69 

Paralexia, 102 

Parasites on eyelashes, 260, 261 

Paretic dementia, 164 

atrophy of optic nerve, 164 
muscular disorders of eye, 166 
ocular migraine, 169 
pathology, 169 
reflex rigidity of pupil, 167 

Parturition and childbed, ocular ef- 
fects during, 319, 320 

Pellagra, 400 

ophthalmoscopic findings, 400 

Pemphigus of conjunctiva, 259 

Peripheral visual disorders, ophthal- 
moscope in, 41 

Pest, 399 

Pharyngeal catarrh, chronic, 266 

Phenol, 350 

Phosphorus, 350 

Photochemic actions in retina pro- 
duced by light, 30 

Photophobia, 32 

Phthiriasis of eyelids, 260 

Physostigmine, 350 

Picric acid, 350 

Pilocarpine, 350 

Piscidium, 350 

Plethora, 288, 430 

Podophyllin, 350 

Poisons, 324 

Poisons and infectious diseases, 324 

Poisoning, acute and chronic, symp- 
toms of, in eye, 325, 326 

Polio-encephalitis, hemorrhagic, at 
floor of fourth ventricle, 73 

Polio-encephalitis, superior, 177 
anatomical lesion in, 178 

Porencephaly, 175 

Potassium bromide, 334 

Potassium chlorate, 388 

Potassium cyanide, 339 

Pregnancy, ocular effects during, 318, 
319 

Progressive ophthalmoplegia, 177 

Prussic acid, 351 

Psychic blindness, 90 

Ptomaines, 358, 359 

Ptosis, 85 



464 



INDEX. 



Pulvinar, the, 45, 47, 51, 53, 54 
Pupils, 

abnormalities in size, of a central 
character, 119 

anomalies of the movements of, 111 

difference in size of, 114 

dilatation of, after cutaneous irri- 
tation, 117 

hem iopic reaction of, 113 

hemiopic rigidity of, 113 

Haab's cortical reflex of, 110 

inaction, hemiopic, 112 

narrowing of, in paralysis of sym- 
pathetic, 118 

nystagmus of, 116 

paradoxical reaction of, 116 

reaction of, in unilateral blindness, 
37 

reflex rigidity of, 113, 114 
Pyaemia, 368 

septic thrombi, 368, 369 



Respiration — sneezing, 285 
Respiratory organs, diseases of, 274 
Respiratory tract, diseases of, 286 

conjunctival abscesses, 286, 287 

herpes cornese in bronchitis and 
pneumonia, 286 

operation for empyema, ocular 
effects following, 287 

sympathetic nerve symptoms in 
pulmonary diseases, 286 
Rheumatism, 372 

cyclitis, 373 

endocarditis, 373 

inflammation of Tenon's capsule, 
373 

iritis, 372, 373 

keratitis, parenchymatous, 373 

micro-organisms, 374 

optic neuritis, 373 

scleritis, 373 
Rotheln, 376 



Quinine, 351 

Rachitis, 446 

laminated cataract in, 446, 447, 448 
Reflexes, involuntary, from the visual 

organ, 67 
Relapsing fever, 384 

choroiditis, 385 

conjunctival catarrh, 381 

cyclitis, 384 

hypopyon, 385 

uvea, influence of, 385 

vision, disorders of, 384 
Retinal ansesthesia, 32 

color sense, disturbance of, 32 

ophthalmoscopic appearances, 32 
Retinal asthenopia, 31 
Retinal hemorrhages in extensive cuta- 
neous burns, 261 
Retinal hypersesthesia, 31 
Retinal vessels, pulsation of, 292, 293 
Retinitis pigmentosa in cirrhosis of 

liver, 272, 273 
Resorcin, 352 
Respiration and its abnormalities, 283 

irritation of conjunctiva, effect 
upon breathing, 284 

pupils in suffocation, 284 

retinal veins in dyspnoea, 284, 285 



Santonin, 352 
Saponin, 353 
Scarlatina, 376 

conjunctival catarrh in, 376 
eye affections due to complications, 
376, 377 
Scintillating scotoma, 64, 237-239 
migraine as a symptom of, 239 
Scrofula, 424 

chronic catarrhs of mucous mem- 
brane, 425 
eczema of conjunctiva and cornea, 

424 
phlyctenular disease of conjunctiva 
and cornea, 424 
Seborrhoea, 254 
Secale cornutum, 354 
Sensory nerves, disorders in domain of, 
107 
cornea, hysterical anaesthesia of, 

in, 108 
cornea, peripheral anesthesia of, 

in, 107 
keratitis, neuro-paralytic, in, 107 
Sensory nerves, 
course of, 25 
origin of, 25 

peripheral irritation of, 107 
peripheral paralysis of, 107 



INDEX. 



465 



Septicaemia, 368 

fatty degeneration, 368 

retinal hemorrhages, 368 
Sexual organs, diseases of, 311-333 
Silver, 354 

Skin, diseases of, 246 
Sleep, 

eye in, 229 

nature of, 228 
Small -pox, 378 

conjunctiva in, 378 

eye diseases as sequelae to, 380 

eyelids in, 378 

lachrymal passages, inflammation 
of, 379 

purulent keratitis, 379 

retinal hemorrhages, 379 
Snake virus, 354 
Snow blindness, 35 
Sodium salicylate, 352 
Somnolence, 178 
Speech, central disorder of, 99 

acoustic disorders in, 104 

examination, 103 

optical disorders, 104 
Spermatorrhoea, 313 
Sphincter pupillae, spasm of, 117 
Spinal cord, diseases of, 183 

injuries of, 199 

concussion of spine, 200 
Splenic fever, 371 
Spring catarrh of conjunctiva, 356, 357, 

258 
Stimulus, differential, 36 

initial, 36 
Strabismus convergens, visual disturb- 
ance in, 83 
Strychnine, 354 
Sulphur chloride, 355 
Sulphur pomade, 355 
Sulphuretted hydrogen, 355 
Sulphuric acid, 355 
Sulphuric ether, 355 
Sunstroke, 175 
Sympathetic and involuntary muscles 

of eye, disorders of, 109 
Syphilis, 404 
Syphilis, acquired, 404-416 

arteritis, 407, 410, 413 

chancre of eye, 404, 405 

choroiditis, 407, 408, 409, 411 ' 
30 



Syphilis, acquired, conjunctiva, affec- 
tions of, 413 

cyclitis, 407 

dacryocystitis, 413 

eruptions on lids, 405 

gummata, 406, 407, 411, 412, 413, 
414 

iritis, 405, 406, 407 

keratitis, 411 

neuritis, basilar, 414 

optic nerve, affections of, 414 

paralyses, 415, 416 

periostitis of orbital walls, 413 

retinitis, 406 

retinitis pigmentosa, 409, 410, 416 

Tenon's capsule, disease of, 411 
Syphilis, congenital, 416-430 

choroiditis, 417, 418 

gummata, 419 

iritis, 418 

keratitis, 418, 419 

optic nerve, affections of, 417 

orbital walls, 419 

paralyses, 419, 420 

retinitis, 417, 418 

treatment, 430 

Tabes dorsalis, 183 

color disturbances, 185 

epiphora, 194 

gray atrophy in, 184, 186, 190 

muscular paralyses, 189, 190 

ophthalmoscopic examination, 183 

pupillary symptoms, 193 

sensory disturbances, 194 

tension of the globe, 194 

treatment, 187 

vision, disturbances of, 185, 189 
Tea, 356 
Teeth, diseases of, 266 

due to ocular affections, 268 

ocular affections due to, 266, 367, 
368 
Teething, relation to reflex neurotic 

conditions of eye, 366 
Tetanus, 343, 371 

entrance for infection through eye, 
343 
Tetany, 343 

mydriasis, 343 

neuro-retinitis, 343 



466 



INDEX. 



Tetany, pupillary changes, 243 
Thomsen's disease, amblyopia, 244 

contractures, 244 

exophthalmus, 244 

Graefe's sign, 244 

hypertrophy of muscles of eye, 244 
Thrombosis, cerebral, 135 

diagnosis and symptoms, 136 

infectious, 135 
Thrombosis in eye, 296, 297 
Thyroid, disease of, 298 
Transcortical disorders of vision, 86 
Traumatic neurosis, 224 
Trichinosis. 269, 404 
Trigeminal fibres, cortical termination 

of, 108 
Trigeminus nerve, 

branches of, 25 

course of, 25 

origin of the sensory root of, 25 
Trigeminus nerve, diseases of, 206 

cataract in, 11 

corneal changes after division of 
sympathetic, 208, 209 

corneal changes after destruction 
of ganglion cells, 209 

inflammation of first and ocular 
branches, 206 

keratitis, neuro-paralytic, 207, 208 

keratitis, ulcerative, 207 

special trophic fibres in, 207 
Trochlearis, nucleus and course of, 

200 
Trophoneuroses, 200 

acromegaly, 201 

hemiatrophy, progressive facial, 
202 

syringo-myelia, 200 
Tobacco, 329, 356, 357 
Torpor retinae, 34 
Toxalbumin and ptomaines, 358 
Tuberculosis, 420 

of bony walls, 423 

of central parts, 423 

chalazion, bacilli in, 421 

of chiasm, 423 

of choroid, 422 

infection, eye as a point of en- 
trance of, 420 

of iris, 422, 423 

lupus of conjunctiva, 421 



Tuberculosis — miliary nodules of con- 
junctiva, 420, 421 

of optic nerve, 423 

phlyctenulse, 424 

of retina, 422 

ulceration of conjunctiva, 420, 421 

of uvea, 422 
Tumor cachexia, 456 

auto- intoxication, 454, 455 

metastases in the eye, 452, 453 

toxic effects from virus introduced 
into body, 454 

toxic productions of malignant 
tumors, 452 
Tumors of the brain, 138 

aneurismal, 147 

choked disc, 140, 144 

course and symptoms, 138 

metastatic, 149 

neuritis, simple, 147 

optic nerve, 143, 147 

vision, sudden disturbance of, 
146 
Tumors of spinal cord, 198 
Typhoid fever, 381 

cataract, 383 

choroiditis, 383 

conjunctiva, affections of, 381, 
382 

cornea, affections of, 382 

cyclitis, 383 

dilatation of pupil, 382 

iritis, 383 

muscular paralyses, 383 

neuritis, 382 

paresis, 381 

retinitis, 383 
Typhus fever, 384 

Urinary organs, diseases of, 299 

albuminuria, intra-ocular effects, 

299 
cataract, 306 
chorio-retinitis, 306 
conjunctival hemorrhage, 305 
hemorrhagic glaucoma, 306 
hemorrhages of retina, 300, 301, 

305 
intra-cranial symptoms in albu- 
minuria, 306 
iritis, 306 



INDEX. 



467 



Urinary organs, diseases of, 

mydriasis during eclampsia, 309 
after occlusion of ureters, 309 
after extirpation of kidneys, 
309 
oedema of eyelids, 299 
optic nerve, hemorrhages into, 306 
paralyses of ocular muscles, 307 
retinitis albuminurica, 300-306, 
308, 309 
anatomical lesions, 302, 303 
uraemic amblyopia and amaurosis, 
308, 309 
Uterine disease, a cause of iritis, 
323 

Vaccination, 380 

accidental inoculation of lids or 

conjunctival sac, 380 
keratitis, 381 
Valvular disease, 

hemorrhages into eye, 295 
venous congestion of retina, 29o, 
296 
Varicella, 381 
Venous stasis, 288 
Vertige paralysant, 399 
Vicarious hemorrhages into the vitre- 
ous, 271 



Vision, cortical disorders of, 57 

central disorders of, 65, 66 
Vision, transcortical disorders of, 86 
Visual disorders, intermediate, 43 
Visual impressions, memory centre 

for, 101 
Visual sphere, 

functions remaining after destruc- 
tion of a, 80 
phenomena produced by destruc- 
tion of a. 78 

Warts, miliary, of conjunctiva, 258, 

259 
Wernicke's symptom, 40 
AVhooping-cough, 396 

conjunctivitis, 396 

epiphora, 396 

hemorrhages, 396 

muscular paralyses, 397 

optic neuritis, 397 

phlyctenulae, 397 

photophobia, 396 
Word-blindness, 101 

Xanthelasma, 260 

Yellow atrophy of liver, 272 
Yellow fever, 399 



